Alterations In Surgical Technique Research Articles

Small Joint Arthroplasty of the Hand: An Update on Indications, Outcomes, and Complications.

Small joint arthroplasty of the hand is a well-established surgery that can preserve motion and provide reliable pain relief, joint preservation, and improvement in hand function. Soft-tissue integrity is critical in patient and implant selection to avoid postoperative joint instability. Although instability is more common in nonconstrained implants such as pyrocarbon, silicone arthroplasty is associated with high rates of late implant fracture and failure with resultant recurrent deformity and instability. Additional complications such as stiffness, extension lag, and intraoperative fractures may be mitigated by alterations in surgical technique and postoperative rehabilitation protocols. Revision arthroplasty with soft-tissue stabilization procedures have reliable outcomes and can avoid conversion to arthrodesis. This article will review the surgical indications, outcomes of small joint arthroplasty in the hand, and common complications and their management.

Avoiding Glenoid Baseplate Fixation Failure by Altering Surgical Technique for Varying Bone Densities.

Background:Glenoid baseplate failure is one of the causes of revision and poor outcomes in reverse shoulder arthroplasty (RSA). The objective of this study was to determine whether alterations in surgical technique can improve time-zero fixation of the baseplate in varying bone densities. A secondary objective was to identify whether preoperative radiographic glenoid sclerosis width was associated with the implementation of these techniques.Methods:This study included a biomechanical analysis and a retrospective radiographic review. The biomechanical portion describes 2 alterations to the standard surgical technique (under-preparation [A1] or over-preparation [A2] of the central screw pilot hole) and determined their torque-compression relationship via bone-substitute blocks with varying densities. Patients who underwent the described technical alterations were identified from a registry database of primary RSAs performed between 2007 and 2020. These patients were matched to patients who underwent the standard surgical technique, and preoperative radiographs were compared. Interrater reliability testing was performed to determine reproducibility.Results:With respect to the biomechanical arm, the average compressive force of the baseplate in the low-density block model when using the standard technique was 112 N compared with 300 N for the A1 technique (p = 0.01). In the high-density bone model, the standard technique resulted in failure to seat the baseplate, or screw breakage. Performing the A2 technique, the baseplate was seated without failure, with an average compressive force of 450 N. In the clinical arm, retrospective intraoperative video review for use of the alternative techniques found 20 shoulders in the “low-density” cohort and 21 in the “high-density” cohort. There was a significant difference in the glenoid sclerosis thickness between the experimental and matched control groups in our “high-density” cohort (p = 0.0014). The interrater reliability coefficient was found to be 0.69 for the “low-density” glenoid sclerosis thickness measurement and 0.92 for the “high-density” measurement.Conclusions:In low- and high-density bone models, alterations in surgical technique significantly improved compression and improved the ability to successfully seat the glenoid baseplate. Preoperative radiographs can assist in indicating the alternative technique in the sclerotic glenoid.Clinical Relevance:Utilization of these techniques intraoperatively will improve time-zero fixation of the glenoid baseplate and potentially avoid failure of fixation.

Laparoscopic Hysterectomy with Cervicovaginal Agenesis

Video Objective We present a laparoscopic surgical approach for hysterectomy in Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome with cervicovaginal agenesis. Laparoscopic approaches for removal of uterine remnants have been published with only reports of laparotomy described for hysterectomy with cervicovaginal agenesis. Setting We discuss the diagnosis, management considerations and preoperative planning for definitive surgical treatment of a patient with MRKH with cervicovaginal agenesis presenting with hematometra and pain. Patient initially presenting with primary amenorrhea and pain, with previous medical treatment to achieve amenorrhea. Interventions Laparoscopic hysterectomy with bilateral ureterolysis and uterine artery ligation in a patient with cervicovaginal agenesis. Conclusion We show that laparoscopic hysterectomy is a viable and safe option in patients with cervicovaginal agenesis. The importance of preoperative imaging to rule out associated anomalies and assist in surgical planning is stressed. We highlight necessary alterations in surgical technique to overcome the lack of traction, identify potential anomalous vasculature and ultimately maintain hemostasis, clear delineation of surgical anatomy, and avoid injury. Tissue extraction through laparoscopic in bag morcellation is performed thus avoiding mini laparotomy altogether.

Indications for Penile Prosthesis Revision: Lessons Learned to Limit Technical Causes of Reoperation

IntroductionReoperations are necessary in approximately 30% of penile prostheses over 15 years following original implantation. AimTo determine the most common indications for initial penile prosthesis reoperation at our institution and to describe technical alterations that have improved postoperative outcomes. MethodsA retrospective review of all patients who underwent penile prosthesis reoperation surgery at a single, high-volume Canadian center between 2006 and 2018 was performed. Patient demographic information, prosthetic device factors, and surgical complications were analyzed. Main Outcome MeasureThe primary outcomes were the indications for and variables associated with initial penile prosthesis reoperation. ResultsDuring the study period, 99 first-time penile prosthesis reoperations were performed out of 1,161 penile prosthesis procedures (Figure 1). This included 14 (14.1%) explants, 32 (32.3%) revisions, and 53 (53.5%) explant and reimplants. Indications for reoperation included 49 (49.5%) mechanical failures, 28 (28.3%) technical causes (such as correction of malposition or device herniation), and 12 (12.1%) procedures to treat chronic postoperative pain. Median follow-up was 78.5 months, and median time to reoperation was 46 months. Mechanical failures commonly occurred in the tubing (n = 13, 26.5%) and cylinders (n = 13, 26.5%). The most frequently repositioned component was the valve pump (n = 11, 39.3%). Infection-related indications for reoperation were uncommon (n = 10, 10.1%). Clinical ImplicationsMore than a quarter of penile prosthesis reoperations may have been preventable with alterations in surgical technique, device positioning, and postoperative care. Strengths and LimitationsThis study evaluates a range of indications for initial penile prosthesis reoperation performed by a high-volume single surgeon over a 12-year period. Limitations include the retrospective nature of the study, loss of patients to follow-up, and lack of etiological determinants of prosthesis failure. ConclusionsReoperation for device repositioning and herniation was required for more than a quarter of the initial penile prosthesis implants. Modifications in surgical technique and perioperative care can help reduce the incidence of these technical causes for reoperation.Chan EP, Punjani N, Campbell JD, et al. Indications for Penile Prosthesis Revision: Lessons Learned to Limit Technical Causes of Reoperation. J Sex Med 2019; 16:1444–1450.

Single centre review of the use of costal cartilage for reconstruction of the nasal dorsum

Reconstruction of the nasal skeleton aims to allow optimal air passage as well as a cosmetically pleasing appearance. Autogenous graft materials are the gold standard due to low extrusion and infection rates. A larger source of cartilage is required for complex secondary nasal reconstruction which makes costal cartilage an ideal source of autogenous material. We performed a retrospective review of all patients undergoing nasal reconstruction with autogenous costal cartilage between the years 2005 to 2016. All procedures were performed by a single surgeon across two hospital sites. Patient charts were reviewed to determine aetiology, indication for surgery, referral source, post-operative complications, need for revision surgery and the length of follow-up. There was a total of 28 patients, 68% male with an average age of 37 years. The majority were referred from ENT (50%) followed by plastic or maxillofacial surgeons (21%). The commonest indication for surgery was previous nasal trauma (53%), and 88% of patients with trauma as the aetiology had previous nasal surgery prior to costal cartilage reconstruction. The commonest complication was warping of the costal cartilage graft; this occurred in 18% of patients; a slipped costal cartilage graft occurred in 4%. The revision rate was 32%. There were no cases of pneumothorax, pleural tear and post-operative infection. Despite the availability of alternative cartilage sources and the risk of cartilage warping, autogenous costal cartilage is still the ideal cartilage source for complex nasal reconstruction. It is readily available, durable and versatile. Several recent studies have reported alterations in surgical technique to reduce warping. This will subsequently reduce rates of revision surgery and ensure this versatile cartilage source continues to be utilised by surgeons in future. Level of Evidence: Level IV, therapeutic study

Patient selection for radical surgery for mesothelioma—prognostic factors in a multimodality approach

Research has focused on identification of selection criteria for surgery in a multimodality therapy approach since 1976, when Butchart in Newcastle, UK described the importance of precise patient selection for surgery. He was one of the pioneers in mesothelioma surgery and concluded, after a series of 29 patients undergoing pleuropneumonectomy, that death could have been prevented by better case selection, alteration in surgical technique, and better postoperative management (1). To optimize patient selection, many factors have to be taken into account: the patients’ performance status (PS), the stage of disease, and also availability and access to different treatment approaches. In the following chapter, clinical and pathological staging and prognostic factors will be summarized.

The Pathoanatomy of Congenital Cervical Stenosis: The Triangle Model

Introduction Congenital cervical stenosis (CCS) describes a patient with a decreased spinal canal diameter at multiple levels of the cervical spine in the absence of degenerative changes. Despite recognition of CCS throughout the literature, the anatomical features that lead to this condition have not been established. Knowledge of the pathoanatomy behind CCS may lead to alterations in surgical technique for this patient population that may improve outcomes. Methods From 1,000 cervical MRIs between January 2000 to Dec 2014, CCS was identified in 68 patients using a strict definition of age less than 50 years with mid-sagittal canal diameters (<10 mm) at multiple sub-axial cervical levels (C3-C7). A total of 68 patients met the inclusion criteria for this group. Fourteen controls with normal SCDs (>14 mm) at all cervical levels were used for comparison. Anatomic measurements obtained at each level (C3-C7) included: coronal vertebral body, AP vertebral body, pedicle width, pedicle length, laminar length, AP lateral mass, posterior canal distance, lamina-pedicle angle and lamina-disc angle. Statistical significance was defined as p < 0.01. Results CCS patients demonstrated significantly different anatomical measurements when compared with controls. Significantly smaller lateral masses, lamina lengths, lamina-pedicle angles and larger lamina-disc angles were identified at levels C3-C7 in the CCS group ( p < 0.01). These anatomic components form a right triangle that illustrates the cumulative narrowing effect on space for the spinal cord. Conclusions The pathoanatomy of CCS is associated with a decrease in the lamina-pedicle angle and an increase in the lamina-disc angle. These changes in the alignment of the bony posterior elements lead to decrease in lamina length and ultimately to a smaller cross sectional area for the spinal cord. The global changes in CCS are best illustrated by this triangle model and driven by the posterior elements of the cervical spine.

The Triangle Model of Congenital Cervical Stenosis

Retrospective Cross-Sectional Study OBJECTIVE.: Identify the pathoanatomical features of the cervical spine associated with congenital stenosis SUMMARY OF BACKGROUND DATA.: Congenital cervical stenosis (CCS) describes a patient with a decreased spinal canal diameter at multiple levels of the cervical spine in the absence of degenerative changes. Despite recognition of CCS throughout the literature, the anatomical features that lead to this condition have not been established. Knowledge of the pathoanatomy behind CCS may lead to alterations in surgical technique for this patient population that may improve outcomes. From 1000 cervical MRIs between January 2000 and December 2014, CCS was identified in 68 patients using a strict definition of age less than 50 years with mid-sagittal canal diameters (mid-SCD) (<10 mm) at multiple sub-axial cervical levels (C3-C7). A total of 68 patients met the inclusion criteria for this group. Fourteen controls with normal SCDs (>14 mm) at all cervical levels were used for comparison. Anatomic measurements obtained at each level (C3-C7) included: coronal vertebral body, AP vertebral body, pedicle width, pedicle length, laminar length, AP lateral mass, posterior canal distance, lamina-pedicle angle, and lamina-disc angle (LDA). Statistical significance was defined as P < 0.01. CCS patients demonstrated significantly different anatomical measurements when compared with controls. Significantly smaller lateral masses, lamina lengths, lamina-pedicle angles, and larger LDAs were identified at levels C3 to C7 in the CCS group (P < 0.01). These anatomic components form a right triangle that illustrates the cumulative narrowing effect on space for the spinal cord. The pathoanatomy of CCS is associated with a decrease in the lamina-pedicle angle and an increase in the LDA ultimately leading to a smaller SCD. The global changes in CCS are best illustrated by this triangle model and are driven by the posterior elements of the cervical spine. 4.

Sagittal balance is more than just alignment: why PJK remains an unresolved problem.

BackgroundThe durability of adult spinal deformity surgery remains problematic. Revision rates above 20 % have been reported, with a range of causes including wound infection, nonunion and adjacent level pathology. While some of these complications have been amenable to changes in patient selection or surgical technique, Proximal Junctional Kyphosis (PJK) remains an unresolved challenge. This study examines the contributions of non-mechanical factors to the incidence of postoperative sagittal imbalance and PJK after adult deformity surgery.MethodsWe reviewed a consecutive series of adult spinal deformity patients who required revision for PJK from 2013 to 2015 and examined in their medical records in detail.ResultsNeurologic disorders were identified in 22 (76 %) of the 29 PJK cases reviewed in this series. Neurologic disorders included Parkinson’s disease (1), prior stroke (5), metabolic encephalopathy (2), seizure disorder (1), cervical myelopathy (7), thoracic myelopathy (1), diabetic neuropathy (5) and other neuropathy (4). Other potential comorbidities affecting standing balance included untreated cataracts (9), glaucoma (1) and polymyositis (1). Eight patients were documented to have frequent falls, with twelve cases having a fall right before symptoms related to the PJK were noted.ConclusionPJK is an important contributing factor to the substantial and unsustainable rate of revision surgery following adult deformity correction. Multiple efforts to avoid PJK via alterations in surgical technique have been largely unsuccessful. This study suggests that non-mechanical neuromuscular co-morbidities play an important role in post-operative sagittal imbalance and PJK. Recognizing the multi-factorial etiology of PJK may lead to more successful strategies to avoid PJK and improve surgical outcomes.

Angiographic identification of extrahepatic perfusion after hepatic arterial pump placement: implications for surgical prevention

BackgroundHepatic arterial infusion (HAI) chemotherapy is an effective treatment for patients with liver malignancy. Extrahepatic perfusion (EHP) after HAI pump placement requires correction prior to starting chemotherapy. The aim of this study was to define the origin of arterial branches causing EHP in order to determine if alterations in surgical technique during pump placement might prevent EHP. MethodsA prospectively maintained, single-centre HAI database was reviewed for all patients (2008–2011) with EHP. The origin of arterial branches causing EHP was classified anatomically and patient outcomes were analysed. ResultsOf the 327 patients with pumps implanted, 24 evidenced EHP. The arterial branch responsible for EHP perfused the duodenum, pancreas and/or stomach. The branch responsible for EHP arose from the proper hepatic artery (PHA), 1st, 2nd, or 3rd order hepatic artery branches in 7, 10, 5 and 2 patients, respectively. The majority of branches beyond the PHA causing EHP (13/17) originated from the right hepatic artery. In 18 patients, aberrant branches were successfully treated with embolization. ConclusionThese findings provide the anatomic basis for prevention of up to one-third of the cases of EHP intra-operatively, decreasing the number of patients who will require additional procedures for correction of EHP post-operatively.

Multivariate analysis of risk factors for surgical site infection after laparoscopic colorectal surgery

Surgical site infection (SSI) and incisional hernia (IH) are among the most common complications after colorectal surgery. While many risk factors for these complications are unavoidable, evidence suggests that use of Pfannenstiel incisions for specimen extraction during laparoscopic procedures may reduce their incidence. The objectives of this study were to identify risk factors for extraction site SSI (primary objective) and IH (secondary objective) in patients undergoing laparoscopic colorectal surgery. Patients who underwent laparoscopic colorectal resections at The Ohio State University Wexner Medical Center between January 2006 and October 2012 were included. In addition to reviewing medical records, data were gathered from patient questionnaires with a focus on two end points: extraction site SSI and IH. Univariate logistic regression analysis was performed to identify significant associations between the two end points and the following variables: age, gender, ASA (American Society of Anesthesiologists) score, cancer, inflammatory bowel disease (IBD), body mass index (BMI), diabetes, chronic obstructive pulmonary disease, use of immunosuppressant medications, chemotherapy, radiation therapy, smoking, surgical history, surgery duration, duration of follow-up, use of hand-assistance, and utilization of Pfannenstiel incisions for specimen extraction. Multivariate analysis was performed for significant variables. A total of 419 patients met the inclusion criteria. The incidence of SSI was 10.3%. Higher BMI, presence of IBD, younger age, and hand-assisted procedures were associated with a significantly higher risk of SSI. Use of Pfannenstiel extraction sites was associated with lower infection rates; however, this association was not statistically significant. IBD, BMI, and hand-assistance were statistically significant on multivariate analysis. Odds ratios for SSI with IBD, hand-assistance and BMI (per unit increase) were 3.3, 2.2, and 1.06, respectively. Alterations in surgical technique and specimen extraction site can reduce wound-related complications after laparoscopic colorectal resections. Remaining risk factors are largely nonmodifiable from a surgeon's perspective.

Alignment Changes Due to Incomplete Component Seating in Total Knee Arthroplasty

Mechanical axis restoration remains a primary goal of total knee arthroplasty. Incomplete asymmetrical component seating, through intended or unintended alterations in surgical technique, changes the component alignment and, thus, the overall mechanical axis. Using a trigonometric analysis, it was determined that incomplete seating of 1 to 5 mm can alter the coronal alignment by 0.7° to 4.9°, depending on the amount of asymmetry as well as the size of the femoral or tibial component. This analysis quantifies the degree of changes surgeons should expect when incomplete component seating is encountered intraoperatively.

First Branchial Cleft Anomaly: Clinical Insight into its Relevance in Otolaryngology with Pediatric Considerations

First branchial cleft anomalies (FBCA) represent a small subset of congenital malformations in neck. Prime objective of this study is to share our experience with FBCA, emphasize its relevance in otolaryngology and deal with its pediatric perspective. Embryology, pathologic anatomy and varied spectra of clinical presentations of FBCA are discussed. Along with this we have illustrated three different cases; all of them were of pediatric age group and were misdiagnosed by their treating specialists elsewhere. In this article we have also laid special emphasis on its pediatric considerations. FBCA are mostly misdiagnosed due to their unfamiliar clinical signs and symptoms. Swellings may masquerade as other neck masses. Majority of patients give a history of previous incision and drainage. While dealing with pediatric patients the important factors to be kept in mind are the age of child, superficial course of facial nerve, any associated agenesis of parotid gland. Alteration in surgical technique may be required in children. A thorough medical examination with high index of clinical suspicion should be kept in mind while dealing with such anomalies. Owing to their complex presentation and close relation with facial nerve they are challenging lesions for surgeons.

Minimising the risk of extensor pollicis longus rupture following volar plate fixation of distal radius fractures: a cadaveric study

Rupture of extensor pollicis longus (EPL) tendon is a recognised complication following volar plate fixation of distal radius fractures, usually from attrition caused by prominent screws. We sought to identify the screw holes in some of the most commonly used plates which may precipitate tendon injury. Three fixed-angle volar locking plates were sequentially positioned into 18 cadaveric arms. A wire was passed through each of the holes in the plates using a locking guide and the dorsal relationships noted. Each plate had specific 'high-risk' holes which directed the wire towards the EPL groove. The central screw holes appeared mostly implicated in EPL injury. Awareness of 'high-risk' holes and appropriate minor alterations in surgical technique may consequently decrease the incidence of EPL irritation and rupture.

Current state of penile rehabilitation after radical prostatectomy

Erectile dysfunction is a major source of morbidity for many men who undergo radical prostatectomy for localized prostate cancer annually. Few areas of urology remain as controversial as penile rehabilitation postprostatectomy, an ill defined treatment strategy designed to minimize the incidence and severity of erectile dysfunction. Contemporary approaches to penile rehabilitation include oral phosphodiesterase type-5 inhibitors, vacuum constriction devices, intracavernous vasoactive injections and attempts at frequent sexual encounters. The intent of penile rehabilitation strategies is to facilitate the recovery of erectile function through preservation of cavernous smooth muscle, though none has definitive evidence of benefit. This review will evaluate the current theories of the cause of postprostatectomy erectile dysfunction, alterations in surgical technique to minimize it, and the application of erectogenic pharmaceuticals to improve recovery of erectile function, or maximize its preservation. A discussion of basic science evidence and clinical trials will be reviewed.

Quality Assurance and Benchmarking for Radical Cystectomy: Monitoring Early Complications and Mortality Using Cumulative Summation Charts

Cumulative summation is one method for quality assurance that has recently been adapted to the medical field to monitor any binary surgical outcomes on an ongoing basis. In this study we used cumulative summation charts for quality assurance in radical cystectomies. Cumulative summation charts were generated from prospectively collected data for the first 150 radical cystectomies performed by a single surgeon from 2001 to 2007. Overall and disease specific survival were estimated using the Kaplan-Meier actuarial methodology and stratified by pathological stage. Based on a literature review acceptable rates were identified as death 0.3% to 4%, ureterointestinal leak 0.3% to 1%, unplanned reoperation 2.3% to 17%, myocardial infarction 0.3% to 2% and pulmonary embolism 0.4% to 2%. Median followup was 16 months. There were 12, 12, 41, 26, 25 and 34 patients with pTis, pT1, pT2, pT3, pT4 and pN+ disease, respectively. The 5-year disease specific survival for less than pT2, pT2, pT3, pT4 and pN+ was 92%, 90%, 60%, 51% and 30%, respectively. The occurrence of postoperative death, rectal injury, ureterointestinal anastomotic leak, immediate reoperation, myocardial infarction and pulmonary embolus for the 150 patients was 1, 0, 3, 2, 2 and 3, respectively. Cumulative summation graphs allowed a visual guide to the key performance indicators. Using cumulative summation surgeons can continuously identify if their morbidity or mortality rates are approaching benchmark limits. This approach may provide more timely information when alterations in surgical technique, patient selection and perioperative care should be considered if benchmark limits are being approached for a variety of surgical outcomes.

Patterns of failure with time of an artificial scaffold class ligament used for reconstruction of the human anterior cruciate ligament

A composite carbon fibre polyester scaffold class ligament (ABC — Active Biosynthetic Composite Ligament, Surgicraft Ltd., Redditch) has been used for primary reconstruction of the torn anterior cruciate ligament at Mayday University Hospital since 1985. A cohort of patients followed up until 1996 showed a high incidence of early failure of the implant due to rupture and stretching. This led to a detailed mode of failure analysis and as a result the surgical technique was modified and new instrumentation was introduced in 1992 leading to a substantial improvement in early and mid-term survivorship. However, from 1996 onwards a large number of patients was lost to follow-up and therefore in 2000 a second cohort of patients was recalled for retrospective review. All the patients in this cohort had undergone surgery after 1992 and following the introduction of new instrumentation and alteration in surgical technique. Review of the results in the second cohort showed a very low initial failure rate (0% in the first 3 years), but with an increasing incidence of failure (27.9%) noted between 5 and 7 years post-operatively.

Barriers to rehabilitation following surgery for primary breast cancer

Surgery is a mainstay of primary breast cancer therapy. Alterations in surgical technique have reduced normal tissue injury, yet pain and functional compromise continue to occur following treatment. A tenuous evidence base bolstered by considerable expert opinion suggests that early intervention with conventional rehabilitative modalities can reduce surgery-associated pain and dysfunction. Barriers to the timely rehabilitation of functionally morbid sequelae are discussed at length in this article. Barriers arise from a wide range of academic, human, logistic, and financial sources. Despite obstacles, expeditious and effective post-surgical rehabilitation is being regularly delivered to breast cancer patients at many institutions. This experience has given rise to anecdotal information on the management of common sequelae that may undermine function. The epidemiology, pathophysiology, and management of these sequelae are outlined in this article with an emphasis on the caliber of supporting evidence. Myofascial dysfunction, axillary web syndrome, frozen shoulder, lymphostasis, post-mastectomy syndrome, and donor site morbidity following breast reconstruction are addressed. A critical need for more definitive evidence to guide patient management characterizes the current treatment algorithms for surgical sequelae.

Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: indications and technical outcomes

Patients undergoing pancreaticoduodenectomy develop postoperative complications related to surgery and their disease. Very little data are available on the role or success of endoscopic retrograde cholangiopancreatography (ERCP) in such patients. The aim of this study was to evaluate the indications and role of diagnostic and therapeutic ERCP after pancreaticoduodenectomy for both benign and malignant disease. This study was a 10-year (1990 - 2000) single institution retrospective review of all ERCPs performed on patients who had undergone pancreaticoduodenectomy surgery. Indications for the ERCP and technical procedural success were studied. 29 patients with a pancreaticoduodenectomy underwent 56 ERCPs. Reasons for surgery were neoplasia and chronic pancreatitis. Indications for ERCP included evaluation of jaundice and pain. Technical success related to the clinical indication (jaundice 69 %, pain 54 %). ERCP plays an important role in the management of postpancreatic surgery problems including biliary and anastomotic strictures, and should be the modality of choice. However, surgical technique may make the afferent limb inaccessible, and the ductal anastomosis difficult to identify in patients with some types of pancreaticoduodenectomy. Closer collaboration between surgeon and endoscopist may allow alterations in surgical technique to improve postoperative ERCP success.

Reoperations on the Ascending Aorta and Aortic Root in Patients With Previous Cardiac Surgery

First time operations on the ascending aorta are performed with low mortality, few complications, and excellent long-term results. Reoperations for aortic pathology in patients with previous cardiac surgery carry significantly more risk. Technical issues during the procedure, as well as age, preoperative New York Heart Association class, and perioperative renal dysfunction, have been shown to contribute heavily to worse outcomes. We analyzed our results with aortic reoperations with the intent of further reducing surgical risk through alterations in surgical technique or patient selection. From July 1997 until October 2005, 147 patients having previous cardiac surgery presented with aneurysm or dissection of the ascending aorta or root. Perioperative data were retrospectively analyzed. Morbidity, mortality, and risk factors for these events were calculated. Eight patients expired (5.4%) after their reoperation. Significant (p < 0.05) univariate risk factors for mortality included age greater than 75 years (< 0.001), previous coronary artery bypass grafting (CABG) (< 0.008), cardiopulmonary bypass greater than 240 minutes (< 0.01), need for intraaortic balloon pump support (< 0.001), need for new CABG (< 0.007), postoperative cerebrovascular accident (< 0.032), and tracheostomy (< 0.003). Age 75 years or older (p < 0.025) was the only significant variable for death by multivariate analysis. A majority of patients (n = 87, 60%) required circulatory arrest to complete their procedure. However, neither arch involvement nor type of aortic root procedure was predictive of perioperative mortality. Surgery on the ascending aorta and root in patients who have had previous cardiac surgery can be performed with low mortality. Advanced age and significant coronary disease may negatively influence surgical results.