Adequacy Of Repair Research Articles

Role of Microbiome in the Outcomes Following Surgical Repair of Perianal Fistula: Prospective Cohort Study Design and Preliminary Results.

Anal fistulae are common, predominantly cryptoglandular, and almost invariably require surgical treatment. Recurrences are common for procedures other than fistulotomy regardless of technique and adequacy of repair. Growing evidence supports the pivotal role of specific intestinal bacteria in anastomotic failures after bowel resection. Anal crypts harbor colonic microbiota suggesting that similar mechanisms to anastomotic healing might prevail after anal fistula repair and hence influence healing. This study aims at assessing the potential role of the intestinal microbiome in the clinical outcomes after surgical repair of cryptoglandular anal fistula. This is a pilot prospective cohort study enrolling patients with anal fistula undergoing endoanal advancement flap. For microbiome analysis, stool samples are taken via rectal swab before the procedure; additionally, a portion of the fistula is collected intraoperatively after fistulectomy. Samples from groups with treatment failure are compared to samples from patients who healed after surgical repair. Alpha and beta diversities and differential abundance of microbial taxa are determined and compared between groups with DADA2 analytical pipeline. Five patients have been enrolled to date (one female, four male). At median follow-up of 6months (2-11), one patient experienced disease recurrence at 3months. DNA from the 5 rectal swab and tissue samples was extracted, showing increased relative abundance of Enterococcus faecalis in samples from the patient who developed a recurrent fistula but not in those without recurrence. These very preliminary data suggest that intestinal microbiome may represent a crucial determinant of the surgical outcomes after anal fistula surgery.

Indispensable Role of Transesophageal Echocardiography in Double-Chamber Right Ventricle Repair Surgery

Double-chamber right ventricle repair surgery requires the excision of anomalous obstructive muscular or fibromuscular bundles in the right ventricular outflow tract. Because of the close proximity of key structures in the right ventricular outflow tract, the surgery is extremely challenging and requires precise resection. Underresection of the muscle bands can lead to significant residual gradients in the postoperative period, whereas overenthusiastic resection can cause iatrogenic injury to surrounding structures. Various techniques like Hegar sizing by the surgeons, direct chamber pressure measurement, transesophageal echocardiography, and epicardial echocardiography can guide the surgeons about the adequacy of repair. Transesophageal echocardiography is crucial at each step, as it can precisely determine the exact site of obstruction in the preoperative period. Postoperatively, it helps determine the adequacy of surgical repair and identification of inadvertent iatrogenic complications.

Transesophageal Echocardiographic Illustration of Postinfarction Ventricular Septal Rupture

AbstractPostinfarction ventricular septal rupture (VSR) is a rare but dreaded mechanical complication of myocardial infarction. Moreover, patient develops cardiogenic shock or congestive heart failure requiring early surgical intervention. To optimize surgical repair, perioperative confirmation, determining location of VSR and adequacy of repair, is mandatory. Assessment can be obtained by the transesophageal echocardiography (TEE). Use of two- and three-dimensional TEE techniques clearly delineate size and shape of septal rupture and involvement of other cardiac structures. We report a patient presenting with postinfarction VSR for elective VSR repair and surgical revascularization and implication of TEE in perioperative management.

Technical Performance Score Predicts Perioperative Outcomes in Complex Congenital Heart Surgery Performed in a Small-to-Medium-Volume Program.

As the quality of surgical outcomes depend on many factors, the development of validated tools to assess the different aspects of complex multidisciplinary teams' performance is crucial. The Technical Performance Score (TPS) has only been validated to correlate with outcomes in large-volume surgical programs. Here we assess the utility of TPS in correlation to perioperative outcomes for complex congenital heart surgeries (CHS) performed in a small-to-medium-volume program. 673 patients underwent CHS from 4/2012 to 12/2017 at our institution. Of those, 122 were STAT 4 and STAT 5. TPS was determined for each STAT 4 and STAT 5 operation using discharge echocardiogram: 1 = optimal, 2 = adequate, 3 = inadequate. Patient outcomes were compared including mortality, length of stay, ventilation times, and adverse events. 69 patients (57%) were neonates, 32 (26%) were infants, 17 (14%) were children, 4 (3%) were adults. TPS class 1 was assigned to 85 (70%) operations, TPS class 2 was assigned to 25 (20%) operations, and TPS class 3 was assigned to 12 (10%) operations. TPS was associated with re-intubation, ICU length of stay, postoperative length of stay, and mortality. TPS did not correlate with unplanned 30-day readmissions, need for reoperation, and inotropic score. Technical performance score was associated with perioperative outcomes and is a useful tool to assess the adequacy of repair for high complexity CHS in a small-to-medium-volume surgical program. TPS should be a part of program review in congenital heart programs of all sizes to identify strategies that may reduce postoperative morbidity and potentially improve long-term outcomes.

MULTICENTER VALIDATION OF TECHNICAL PERFORMANCE SCORE AS A QUALITY ASSESSMENT TOOL IN CONGENITAL CARDIAC SURGERY

Technical Performance Score (TPS), a novel tool for assessing adequacy of repair of congenital cardiac defects based on clinical and echocardiographic data, has been validated and correlates with outcomes in single center studies. This study aims to validate TPS in a multicenter environment.

Abstract 220: Technical Performance Scores Predict Outcomes Following Congenital Heart Surgery: Multicenter Validation

BACKGROUND: In previous work from a single center, Technical Performance Score (TPS), a tool that assesses technical adequacy of repair, has been shown to be strongly associated with outcomes in congenital cardiac surgery. We sought to validate the efficacy of TPS in a multicenter environment. METHODS: All patients (1 day to 62 years) who were discharged from January 1 to December 31, 2011; and who underwent 9 congenital cardiac procedures (Arterial switch operation [84], Bidirectional Glenn [75], Atrioventricular canal repair [135], Fontan [97], Arch repair on pump [58], Stage I Procedure [85], Pulmonary valve replacement [116], Tetralogy of Fallot repair [112], and Ventricular septal defect repair [163]); from 5 centers were included. Based on echocardiograms (echo) prior to discharge or death, and unplanned reinterventions at surgical site; TPS was assigned using previously established criteria. Case complexity was determined by RACHS-1 category. Outcomes included (a) major postoperative adverse events (AE) excluding unplanned reinterventions, (b) length of ventilation, and (c) postoperative hospital stay. Adjusted analysis used logistic/linear regression to determine odds ratio (OR) and regression coefficient (b) for each outcome. RESULTS: There were 925 hospital discharges: 418 (45%) were RACHS-1 category 2, 295 (32%) category 3, 85 (9%) category 4, 86 (9%) category 6 and the cohort included 41 (4%) adults. TPS were as follows: 491 (53%) class 1-optimal, 263 (28%) class 2-adequate, 131 (14%) class 3-inadequate and 40 (4%) had no TPS assigned because of a lack of or incomplete echos (NA). There were 26 (2.8%) deaths (81% of deaths were in class 3) and 105 (11%) adverse events. Occurrence of major adverse events, ventilation time and hospital length of stay were all significantly higher in class 3 (Figure). On multivariable analysis adjusting for age, RACHS-1, prematurity, and presence of non-cardiac anomalies; Class 3 TPS was associated with a higher odds of AE (OR 7.4, CI 4.1-13.2, p<0.001), longer ventilation (b 1.9, CI 1.6-2.2, p<0.001), and hospital stay (b 1.6, CI 1.4 to 1.8, p<0.001). CONCLUSION: TPS predicts outcomes after congenital heart surgery in a multicenter cohort, and can serve as quality assessment tool. Outcomes may be favorably influenced by focusing on technical excellence.

Optimally invasive mitral valve surgery: a safe and effective approach

Methods Between April 2007 and December 2012, we used a sternum-sparing but optimally invasive approach to MV surgery on 99 patients (mean age 60.71 ± 12.9 years) with mean preoperative EF and LVEDD of 53.8 ± 11.4 % and 56.13 ± 6.9 mm, respectively. Twenty seven patients had previous coronary artery bypass and MV surgeries. All patients had severe mitral insufficiency (MI) from chordal rupture; prolapse of the anterior leaflet, paravalvular leak, endocarditis, floppy MV, and from previous MV surgery. The optimally invasive approach was a rightsided anterolateral thoracotomy at the 5th intercostal space with an approximately 10 cm skin incision. Cardiopulmonary bypass (CPB) was through either cannulation of the ascending aorta or femoral artery with direct bicaval cannulation. Modified Gerbode-Hetzer plication for ruptured chordae and modified Paneth-Hetzer posterior annulus shortening annuloplasty, for annulus dilatation or leaflet prolapse were employed. Paravalvular leaks were closed. Intraoperative TEE was used to evaluate the adequacy of repair or replacement.

Intraoperative Computed Tomography for Repair of Facial Fractures

Objective: To assess the practicality and potential benefitsofintraoperativecomputedtomographyusingamobile scanner in the operating room during repair of orbitozygomatic fractures. Setting: Level I trauma center. Design: Twenty-five patients undergoing open reductionofaunilateraldisplacedfractureofthezygomaand/or repairofablow-outfractureoftheorbitwithcranialbone grafts were placed into a radiolucent head holder and interfaced with the mobile scanner. Spatial vectors were drawn on scans displayed on a computer monitor to allow intraoperative side-to-side comparison of the position of the malar prominences and orbital walls. Corrections of fracture reduction or bone graft position were made as indicated by the comparisons. Results: All scans were accomplished without apparent contamination of the surgical field. Major revisions were performed, based on the scans, in 2 patients whose displaced, comminuted zygoma fractures had been initially reduced with wide exposure of all fracture sites. Minor revisions were performed in 3 patients with displaced but less severely comminuted fractures that had been reduced without exposure of all fracture sites. Bone grafts were repositioned within the orbit in 2 patients with large 2-wall blow-out fractures. Conclusions: Intraoperative computed tomographic evaluation of the adequacy of repair of orbitozygomatic fractures is feasible with the mobile computed tomographic scanner. The scanner allows correction of discrepancies in position of the malar prominences and orbital walls at the time of acute repair, rather than during costly, more difficult delayed revisions. It may eliminate the need for direct visualization of all fracture sites to ensure adequate reduction in selected cases with displaced, comminuted fractures, thus decreasing operating room time and expense. Further study is required to fully document the cost-effectiveness of this approach to facial fracture management.

Differential blockade to assess surgical repair by intraoperative active mobilization in knee injuries-Beyond labour analgesia

Motor-sparing selective epidural analgesia has long been practised in the field of labour analgesia. However, the utility of such techniques in other fields remain limited. We present the successful use of a similar technique of differential blockade in a case of quadriceps plasty with realignment of patella for recurrent dislocation of patella. A very low concentration of bupivacaine and fentanyl was used through continous epidural. The adequacy of repair was assessed intraoperatively by active movement of operated limb by patient himself.

Robot-Assisted Mitral Valve Repair a Single Institution Review

Mitral valve repair (MVR) is the definitive therapy for mitral myxomatous degeneration. Median sternotomy has been the traditional approach to repair until the advent of the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). Minimally invasive surgical approaches for mitral repair have been slow to gain acceptance in cardiac surgery. We review the MVR results from our single-institution academic robotic program. From August 2004 through April 2008, patients who underwent a robotic-assisted (RA) MVR were identified. RA technique included a 4-cm right minithoracotomy, femoral cardiopulmonary bypass with transthoracic aortic occlusion, and RA-MVR. Repair types were combinations of quadrangular/triangular leaflet resection, sliding plasty, chordal transfer/replacement, and edge-to-edge approximation, with band annuloplasty in all cases. Postrepair echocardiography and morbidity follow-ups were completed in all patients. Our primary outcome was adequacy of repair, and secondary outcome was major complications. There were 43 patients (29 male and 14 female) who underwent RA-MVR for severe (4+) mitral regurgitation during the 4-year review. Average operative time was 272.26 minutes. Only one patient had mild postoperative mitral regurgitation, whereas 20 had trace and 22 had no regurgitation after repair. Mean ventilator time was 32.1 hours, and length of stay was 5.7 days. One third of the patients (33%) received postoperative-packed red blood cell transfusions (average: 2.4 units per patient). Twenty-eight percent of patients developed atrial fibrillation after repair. Most of the patients (95.3%) were discharged home. There were no 30-day mortalities. Based on our small single-institution experience, RA-MVR provides an effective treatment for severe mitral valve regurgitation. Although procedure durability is slowly being established, preliminary results are promising. Careful programmatic advances with an integrated team approach can facilitate acceptable postoperative outcomes and excellent MVR.

Surgical Management of Ischemic Mitral Regurgitation

Case presentation: A 62-year-old man visited his cardiologist describing a 6-month history of increasing fatigue and shortness of breath on exertion. His medical history included an inferoposterior myocardial infarction (MI) 3 years previously that was treated with drug-eluting stents to his left circumflex and right coronary arteries. The result of physical examination was remarkable for crackles audible throughout the lower half of both lung fields, an elevated jugular venous pulse to the angle of the jaw, and a grade 3/6 holosystolic murmur loudest at the apex with radiation to the left axilla. An echocardiogram revealed a left ventricular ejection fraction (LVEF) of 15% to 20%, severe mitral regurgitation (MR), and a left ventricular end systolic dimension of 70 mm. The patient underwent a repeat cardiac angiogram that revealed patent stents in the circumflex and right coronary arteries and no other significant stenoses. The decision was made to surgically correct the patient’s MR with a mitral valve operation. He was brought to the operating room, where he was given general anesthesia, and a transesophageal echocardiogram was performed. Examination of the mitral valve revealed poor leaflet coaptation with a degree of leaflet tethering that resulted in severe MR. Inasmuch as the valve leaflets appeared structurally normal, a mitral valve repair procedure using a complete rigid annuloplasty ring was performed. A postoperative echocardiogram revealed trace MR, and the patient experienced no postoperative complications. This patient is a typical example of a growing problem in our aging population, namely, ischemic mitral regurgitation (IMR). IMR clearly has a negative impact on survival in patients with coronary artery disease, even in patients with mild to moderate MR; greater degrees of MR portend an even worse prognosis.1 With almost a fifth of patients who experience an MI followed by the development of IMR,2,3 and over …

Laparoscopic repair of diastasis recti using the ‘Venetian blinds’ technique of plication with prosthetic reinforcement: a retrospective study

Diastasis is a separation of the two recti due to various reasons, and can be measured as the 'inter-recti distance' (IRD). Surgery for diastasis is controversial, while laparoscopic repair has rarely been reported. We describe our method of laparoscopic plication-the 'Venetian blinds' technique combined with mesh reinforcement for patients with diastasis of the recti. A total of 18 patients out of 35 that presented to us were operated. The common indications were cosmesis and discomfort while performing normal activities. Laparoscopic plication with the 'Venetian blinds' technique of the diastasis with prosthetic reinforcement was performed for all cases. The mean body mass index (BMI) was 28.6 kg/m(2) (range 25-32.2) and obese patients had a larger IRD. The mean operating time was 113 min (range 72-154). Minor complications were present in five (27.77%) patients. The recurrence rate after 6-48 months follow up was 0% in this series. Even though surgery for diastasis is controversial, we advocate repair for cosmesis and restoring function of the recti muscles. Our 'Venetian blinds' technique provides a solid repair and reduces the risk of seroma. The use of a prosthesis for the repair is mandatory to prevent recurrence. The adequacy of repair was assessed by measuring the IRD preoperatively and postoperatively with computed tomography (CT) scan. Laparoscopy provides all of the benefits of minimal access surgery.

Experience with intraoperative ultrasound in paediatric cardiac surgery

Intraoperative ultrasound was introduced to evaluate the adequacy of repair after surgical repair of congenital cardiac malformations. Our purpose was to review the evolution of this technique at our centre. We evaluated all intraoperative ultrasound studies undertaken between 1997 and 2002, reviewing the data from 1997 through 2001 retrospectively, but undertaking a prospective audit of studies undertaken from 2002 onwards. In all, we carried out a total number of 639 intraoperative ultrasound studies, from a possible 2737 cardiac operations (23.3%), using the epicardial approach in 580 (90.7%), and transoesophageal ultrasound in the other 59 patients (9.3%). Median age was 0.6 years, with an interquartile range from 0.06 to 3.6 years. The findings obtained using intraoperative ultrasound influenced the surgical management in 63 of the 639 patients (9.9%), suggesting the need for additional surgery in 26, adjustment of the band placed round the pulmonary trunk in 16, preoperative assessment of the cardiac malformation in 5, and confirming the need for prolonged support with cardiopulmonary bypass for impaired ventricular function in 16. There were 18 early reoperations, 5 of which may have been predicted by intraoperative ultrasound. Of the 183 studies reviewed prospectively in 2002, it was not possible to obtain the complete range of views in 8 (4.4%), while in 27 patients (14.7%), the postoperative findings using transthoracic interrogation differed from the findings obtained immediately following bypass. Intraoperative ultrasound is an important technique for monitoring the results of complex congenital cardiac surgery. The immediate recognition of significant lesions, together with multidisciplinary discussion, allows for improved management and prevention of early surgical reintervention.

Initial experience with processed human cadaveric allograft skin for reconstruction of the corpus cavernosum in repair of distal extrusion of a penile prosthesis

We describe our initial experience with the novel application of processed human cadaveric allograft skin in reconstruction of a damaged corpus cavernosum associated with distal extrusion of a penile prosthesis. The material was evaluated for ease of reconstruction, adequacy of repair, and outcome. Human processed dermis allograft requires no intraoperative harvesting, is technically easy to fashion, and offers adequate tensile strength in the reconstruction of damaged corpora cavernosa. This initial experience with processed human cadaveric dermis in reconstruction of damaged corpora cavernosa is encouraging. Further evaluation to define the long-term efficacy and scope of application of this material in urologic reconstructive procedures is warranted.

Intraoperative transesophageal echocardiography for pediatric patients with congenital heart disease.

Intraoperative transesophageal echocardiography for pediatric patients with congenital heart disease.

Minimally Invasive Ligation of Coronary Artery Fistula

Successful surgical occlusion of a left anterior descending coronary artery-to-right ventricular fistula through a minimally invasive route is described. The fistula was ligated epicardially through a small midline pericardial window created in the xiphisternum without myocardial dissection, cardiac arrest, or cardiopulmonary bypass. Intraoperative transesophageal echocardiography played a crucial role in locating the site of the fistula, thereby allowing a minimally invasive surgical approach and assessment of the adequacy of repair.

TRANSAORTIC MESENTERIC ENDARTERECTOMY

Although a number of methods for mesenteric artery reconstruction have been suggested, we believe that patients with atherosclerotic stenosis and occlusion of mesenteric vessels presenting with either acute or chronic visceral ischemia are best managed by either antegrade aortomesenteric bypass or transaortic mesenteric endarterectomy. Antegrade bypass is the most versatile technique and is therefore best adapted to extensive mesenteric disease. Transaortic mesenteric endarterectomy lends itself well to simultaneous renal artery endarterectomy when clinically significant osteal atherosclerosis is present at both sites. With any method of reconstruction, the technical adequacy of repair should be defined intraoperatively. In this regard, intraoperative duplex sonography provides both anatomic and hemodynamic data necessary to ensure technical success and late patency.

Intraoperative Transesophageal Echocardiographic Imaging of Intrapulmonary Tunnel Repair for Anomalous Left Coronary Artery Originating from the Pulmonary Artery.

Reestablishment of aortic flow to the coronary vasculature is the optimal treatment for anomalous origin of the left coronary artery originating from the pulmonary artery (ALCA). We performed intraoperative transesophageal echocardiography (TEE) in five patients (median age 10 months; range 1.5-36 months) who underwent revascularization of the left coronary artery without coronary mobilization by creation of an aortopulmonary window and intrapulmonary tunnel to the os of the anomalous vessel. Tunnel geometry as well as supravalvar pulmonary course were well imaged. Revascularized left coronary artery antegrade flow from the aorta was documented in all via color and pulse wave Doppler. A peribaffle leak (left-to-right shunt) was noted in 2 of the 5 patients, however its presence did not influence left coronary artery flow or clinical outcome. Intraoperative TEE is helpful in assessing adequacy of repair and documenting antegrade aortic flow in the left coronary artery after intrapulmonary tunnel repair for ALCA.

The surgeon's use of epicardial echocardiography during repair of congenital heart defects.

Intraoperative echocardiography in the evaluation of congenital heart defects is a useful method to evaluate surgical anatomy, adequacy of repair, and ventricular performance. Since 1987, 733 patients have undergone epicardial echocardiography during repair. The routine use of this technique has led to the reduction in the need for both early and late reoperation.

Long-term results of surgical repair of coarctation of the aorta--evaluation by exercise test.

Thirty-six patients have been operated on for coarctation of the aorta. The age at operation ranged from 4 to 45 years with a mean of 14 years. Preoperative systolic blood pressure (BP) was above the normal mean + 2 SD in 34 (94%) of the patients. The surgical techniques used for correction of coarctation were: resection and end-to-end anastomosis (50%), resection and graft interposition (25%), patch graft angioplasty (22%) and subclavian artery to descending aorta bypass graft (3%). There was no hospital mortality. Systolic BP measured on hospital discharge available in 30 patients showed an average decrease of 26 mm Hg. The mean follow-up period in 16 of 30 patients (53%) was 7.2 years. All of these patients had a further decrease in systolic BP, and in 14 of 16 (87%) BP was within the mean + 2 SD. Twelve patients were examined in the vascular diagnostic laboratory to determine adequacy of the repair by hemodynamic measures. After average of 7.8 years following operation, all of them had ankle systolic BP higher than brachial systolic pressure; ankle BP did not drop after treadmill walking exercise and the directional Doppler velocity curves from the legs were normal. This study suggested that BP continued to decrease after hospital discharge. We were unable to demonstrate correlation between age at operation and decrease in BP. The adequacy of surgical repair can be assessed by mild effort stress test combined with ankle/arm ratio measurement and directional Doppler velocity curves.