High Risk For Surgical Intervention Research Articles

Comparison of Complication Rates and Postoperative Astigmatism Between Nylon and Mersilene Sutures for Corneal Transplants in Patients with Fuchs Endothelial Dystrophy

The purpose of this study is to evaluate corneal astigmatism and suture-related complications for transplants sutured with nylon and transplants sutured with Mersilene in primary corneal transplants for Fuchs endothelial dystrophy. A retrospective, observational, and comparative study between transplants sutured with either nylon 10-0 or 11-0 (n = 108) or Mersilene 11-0 (n = 58) was done. One hundred sixty-six eyes of 140 patients who received a primary penetrating keratoplasty for Fuchs endothelial dystrophy between 1995 and 2001 at the Rotterdam Eye Hospital in Netherlands were included. Overall, transplant survival did not differ between groups (log-rank test; P = 0.24). During the first 2 years after transplantation, significantly lower astigmatism was seen in transplants sutured with nylon (P = 0.03). Transplants sutured with Mersilene had a significantly higher risk of surgical intervention to correct astigmatism or wound dehiscence after transplantation (hazard ratio, 2.83; 95% confidence interval, 1.34-6.01). Time to first infiltrate, metaplasia (marked scarring along the sutures), or cheesewiring was significantly less in the Mersilene group (P < 0.01). There was a tendency toward a higher risk of complications associated with loose or broken sutures in the nylon group (hazard ratio, 2.00; 95% confidence interval, 0.57-6.98), which was more pronounced after 2 years. During the first years after corneal transplant surgery, Mersilene sutures are associated with a higher risk of complications and more interventions to correct suture-related problems. However, after 2 years, the grafts seem to be able to retain Mersilene sutures with less risk of suture-related complications as compared with grafts with retained nylon sutures. These favorable long-term effects of Mersilene sutures may outweigh its short-term disadvantage in patients with Fuchs endothelial dystrophy.

Anaesthesia for brachytherapy—5½ yr of experience in 1622 procedures

Brachytherapy presents the anaesthetist with unique problems. Information on anaesthesia for brachytherapy, however, is limited. The aim of this paper is to report on our experience involving a large number of brachytherapy procedures. A retrospective analysis of records of 1622 anaesthetic procedures in 952 patients is presented. Records were analysed in respect of patient data, tumour localization, brachytherapy treatment and the type and duration of anaesthetic procedures. More than one-third of patients were at high risk (ASA III or IV) and 40% were more than 60 yr. Repetitive treatments were performed on half of the patients. Breast cancer was the most common indication. The average duration of anaesthesia for pelvic brachytherapy was more than 3 h, with a high degree of variability. Regional anaesthesia was used in 30% of all cases and was the predominant technique for pelvic brachytherapy. Spinal catheter techniques represented a high proportion of those receiving regional anaesthesia. Complications resulting from regional and general anaesthesia were minor and no serious incidents occurred. Based on a large number of procedures, this study gives an example of anaesthetic management in brachytherapy. A substantial minority of patients would be considered high risk for surgical intervention. Regional anaesthesia was the principal technique used when dealing with tumours of the lower body.

Endoscopic repair of gastrostomy after inadvertent removal of percutaneous endoscopic gastrostomy tube.

Percutaneous endoscopic gastrostomy (PEG) tube placement has become the preferred method of enteral feeding for many patients. Neurologic disease and cancer are the most frequent indications for PEG tube placement. PEG tubes are also becoming more frequent in trauma patients for early initiation of enteral feeding. Inadvertent PEG tube removal is a well-known complication of PEG tubes. Patients undergoing PEG tube placement are frequently malnourished and in poor general medical condition, making them relatively high risk for surgical intervention. In the past, after early inadvertent PEG removal, patients underwent laparotomy for surgical repair of the gastrostomy site. Recently, laparoscopic replacement of the PEG tube has been described. We present a new technique of endoscopic repair of the gastrostomy site with hemoclip placement followed by later PEG tube placement.

Cardiac thrombi in a patient with protein-C and S deficiencies: a case report

We report a case of multiple mobile intra-cardiac thrombi accompanying recurrent pulmonary embolism that has been successfully treated by fibrinolytic therapy. Control transesophageal echocardiographic examination showed that prolonged thrombolytic treatment completely removed the thrombi.Surgical removal of emboli has been validated but cannot be proposed to all patients since it is a high-risk intervention. Fibrinolysis is generally efficient but exposes the patient to risk of migration of the intra-cavity thrombus, with occasionally deleterious evolution. Systemic thrombolytic therapy is usually recommended if (a) it is not contraindicated and (b) the thrombi are demonstrated in more than one cardiac chamber, entailing a higher risk of surgical intervention. However, the infusion rate and duration of thrombolytic therapy are important determinants of successful and uncomplicated lysis. Low dose and long infusion time should be chosen to avoid fragmentation of the thrombus and related complications.

Ehlers-Danlos tipo IV con complicaciones vasculares precoces. Descripción de un caso y revisión bibliográfica

Summary Introduction. Ehlers-Danlos Syndrome is a congenital mesenchymal dysplasia characterised by skin and joint laxity. Many clinical types have been described, one of the most notable being the vascular-ecchymotic type IV Ehlers-Danlos because of the risk of arterial, intestinal and uterine rupture, which shortens the life of patients. Arterial ruptures occur mainly in the visceral aorta and arteries, and to a lesser extent in cervical and intracranial arteries or those in the limbs; they appear with minimum traumatic injury. The surgical treatment of these arterial ruptures is complicated owing to the fragility of the arteries and for this reason conservative treatment is preferred. Case report . We describe the case of a female patient previously diagnosed as suffering from Ehlers-Danlos syndrome who, at the early age of 11 years, had a spontaneous retroperitoneal haematoma, as well as ruptures (with the subsequent pseudoaneurysms) of the superficial femoral and brachial arteries with no history of traumatic injury, and another post-catheterisation pseudoaneurysm of the common femoral artery. All of them responded well to medical treatment. Conclusions. When faced with an arterial rupture or aneurysm in young patients, a disease of the connective tissue must be taken into account. Conservative treatment is preferable to a high risk surgical intervention. If surgery is carried out, we recommend the use of simple techniques rather than complex reconstructions. [ANGIOLOGIA 2004; 56: 521-7]

Is Autofluorescence Bronchoscopy Needed to Diagnose Early Bronchogenic Carcinoma?

Is Autofluorescence Bronchoscopy Needed to Diagnose Early Bronchogenic Carcinoma?

Endovascular Exclusion of Leaking Thoracic Aortic Aneurysms

To describe the endovascular exclusion of leaking thoracic aortic aneurysms (TAA). Two elderly patients with leaking TAAs who were at high risk for surgical intervention were transferred to our institution for possible endovascular treatment. Both patients underwent successful endovascular exclusion of the leaking TAAs using multiple stacked AneuRx thoracic endoprostheses. One patient remains alive and well at 1 year with an excluded aneurysm; the other patient died from heart failure 2 months after endografting. While the early results of the endovascular exclusion of leaking TAAs are promising, the use of thoracic endoprostheses remains investigational.

Stereotactic radiosurgery in the management of angiographically occult vascular malformations

Purpose: To evaluate the role of stereotactic radiosurgery in the treatment of angiographically occult vascular malformations (AOVMs). Methods and Materials: From 1987 to 1996, 21 patients, 10 males and 11 females, median age of 41 years (range: 7–75 years), with an intracerebral AOVM underwent stereotactic radiosurgery at our institution. All were considered at high risk for surgical intervention. The vascular lesions were located in the brainstem (17 patients), basal ganglia (2), occipital lobe (1), and cerebellum (1). Diagnosis was based on high-resolution magnetic resonance imaging (MRI). Clinical presentation at onset included previous intracerebral hemorrhage (20 patients) and epilepsy (1). All patients were treated with a linac-based radiosurgical technique. The median dose delivered was 25 Gy (range 13–50 Gy), typically prescribed to the 80–90% isodose surface (range 50–90%), which corresponded to the periphery of the vascular malformation. Patients were followed by clinical neurologic assessment and by MRI on a regular interval basis. Results: Follow-up was obtained in 20 patients; clinical or MRI information was not available for 1 patient, and this patient was excluded from our analysis. At a median follow-up of 77 months (range: 4–141 months), follow-up MRIs postradiosurgery do not demonstrate any changes in the appearance of the AOVM. Four patients developed an intracranial bleed at 4, 8, 35, and 57 months postradiosurgery. Annual hemorrhage rates were considerably higher in the observation period preradiosurgery than postradiosurgery (30% vs. 3.2%, p < 0.001). Complications postradiosurgery were observed in 4 patients. Three patients developed mild to moderate edema surrounding the radiosurgical target, expressed at 5, 8, and 24 months, respectively. In all cases, the edema was transient and resolved completely on subsequent MRIs. One of the 4 patients developed radiation necrosis 8 months after radiosurgery. Conclusion: The use of stereotactic radiosurgery in the treatment of AOVM continues to be controversial. Our results appear to show a reduction in the risk of symptomatic hemorrhage post treatment. Patients with previous history of hemorrhage or progressive neurologic deficit and small, well circumscribed lesions may benefit from a trial of stereotactic radiosurgery.

High risk of surgical intervention in hereditary pancreatitis

Abstract Background The aim of the study was to quantify the risk of surgical intervention in families with hereditary pancreatitis referred to the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Methods Recruitment to EUROPAC started in 1997; families were considered if two or more members had chronic pancreatitis of unknown aetiology. Families were tested for protease serine 1 (PRSS1) mutations using polymerase chain reaction restriction digestion, sequencing the PRSS1 gene-screened negative families. Clinical information about surgical intervention was obtained from family members and referring clinicians, and the cumulative incidence of surgical intervention in the N291 and R122H mutation groups was determined with the Kaplan–Meier method. Results Forty-four families had the R122H mutation, 21 the N291 mutation, and 31 were negative for both. Some 14 (35 per cent) of 40 patients (median age 26·5 (95 per cent confidence interval (c.i.) 21·5–36·3) years) with the N291 mutation had an operative procedure for complications of pancreatitis, compared with 21 (25 per cent) of 83 patients (median age 24 (95 per cent c.i. 13·8–35·8) years) with the R122H variant. This resulted in a cumulative lifetime risk for surgical intervention of 0·6 (95 per cent c.i. 0·5–0·8) for the R122H mutation and 0·6 (0·5–0·8) for the N291 mutation (P = 0·11, log rank test). Conclusion Hereditary pancreatitis carries a significantly increased risk of surgical intervention in this cohort of patients, which equates to an estimated lifetime risk of around 60 per cent. The risk of surgery appears to be independent of PRSS1 mutation type.

Association of upper gastrointestinal surgeons of Great Britain and Ireland

Abstract The following abstracts were presented to the 4th Annual Scientific Meeting of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland on 21–22 September 2000. The British Journal of Surgery prize was awarded to the abstract entitled ‘High risk of surgical intervention in hereditary pancreatitis’ by N. Howes, M. M. Lerch, J. Mössner, S. Endres, J. Deviere, G. Verreman et al.

Trombosis protésica mitral tratada mediante fibrinólisis con dosis acelerada de r-TPA

We report the case of a 53-year-old patient with a mitral prosthesis hospitalized for heart failure. Diagnosis of mitral prosthetic thrombosis, led to a therapeutic disjunction between thrombolysis and surgery. Because of the high risk of surgical intervention, the patient was treated with r-TPA (accelerated infusion), showing immediate, successful response.

Reinterventions for Recurrent Ischemic Heart Disease following a Successful First Re-Do Myocardial Revascularization: Predictors, Indications and Results

Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% ( n = 144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P &lt; 0.001) and in patients with unstable angina (55.6% versus 33.3%. NS) or a Left Ventricular Ejection Fraction (LVEF) &lt; 30% (34.8% versus 20%, P &lt; 0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3 ± 0.3 versus 1 ± 0.6, P &lt; 0.001), proximal occlusive disease ( P &lt; 0.001) and for graft disease of a longer duration (7.18 ± 1.7 years versus 3 ± 0.6 years, P &lt; 0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis &gt; 70% long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG ( n = 48: early 21. late 27). repeat graft angioplasty ( n = 34: early 8. late 26) or transplant ( n = 1). Recurrent symptoms following a second re-do CABG required a graft angioplasty ( n = 6: early 2, late 4), a subsequent re-do CABG ( n = 32) or a transplant ( n = 4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively ( P &lt; 0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.

Reinterventions for recurrent ischemic heart disease following a successful first re-do myocardial revascularization: predictors, indications and results

Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% ( n=144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P<0.001) and in patients with unstable angina (55.6% versus 33.3%, NS) or a Left Ventricular Ejection Fraction (LVEF) <30% (34.8% versus 20%, P<0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3±0.3 versus 1±0.6, P<0.001), proximal occlusive disease ( P<0.001) and for graft disease of a longer duration (7.18±1.7 years versus 3±0.6 years, P<0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis>70%, long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG ( n=48: early 21, late 27), repeat graft angioplasty ( n=34: early 8, late 26) or transplant ( n=1). Recurrent symptoms following a second re-do CABG required a graft angioplasty ( n=6: early 2, late 4), a subsequent re-do CABG ( n=32) or a transplant ( n=4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively ( P<0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.

Refibrinólisis con r-tpa por trombosis de prótesis mitral tras un infarto agudo de miocardio

We report the case of a 62-year-old patient with a mitral prosthesis hospitalized with an anterior acute myocardial infarction who was treated with r-tPA. Some days later, the patient had mitral thrombosis with heart failure. Because of the high risk of surgical intervention, he was successfully treated with a new dose of r-tPA.

Doppler Evaluation of Results of Percutaneous Aortic Balloon Valvuloplasty in Calcific Aortic Stenosis

To evaluate the short-term results of percutaneous aortic balloon valvuloplasty, 55 consecutive elderly patients with symptomatic, severe aortic stenosis who were at high risk for surgical intervention underwent the procedure, with follow-up by clinical evaluation and Doppler echocardiography. Over a mean follow-up of 6.2 months, there were three early deaths (less than 30 days) and eight late deaths. Nine patients underwent subsequent aortic valve surgery, and four had repeat balloon valvuloplasty. Doppler echocardiography revealed a reduction in aortic valve mean gradient from 48 +/- 18 to 33 +/- 12 mm Hg after the procedure (p less than 0.0001) but a return to 46 +/- 16 mm Hg at follow-up (p less than 0.05). The aortic valve area increased from 0.54 +/- 0.15 to 0.85 +/- 0.23 cm2 after the procedure (p less than 0.0001), but there was a significant decrease to 0.67 +/- 0.19 cm2 at follow-up (p less than 0.05). Of patients free of aortic valve operation or death after 30 days after the procedure, 76% wer...

Doppler evaluation of results of percutaneous aortic balloon valvuloplasty in calcific aortic stenosis.

To evaluate the short-term results of percutaneous aortic balloon valvuloplasty, 55 consecutive elderly patients with symptomatic, severe aortic stenosis who were at high risk for surgical intervention underwent the procedure, with follow-up by clinical evaluation and Doppler echocardiography. Over a mean follow-up of 6.2 months, there were three early deaths (less than 30 days) and eight late deaths. Nine patients underwent subsequent aortic valve surgery, and four had repeat balloon valvuloplasty. Doppler echocardiography revealed a reduction in aortic valve mean gradient from 48 +/- 18 to 33 +/- 12 mm Hg after the procedure (p less than 0.0001) but a return to 46 +/- 16 mm Hg at follow-up (p less than 0.05). The aortic valve area increased from 0.54 +/- 0.15 to 0.85 +/- 0.23 cm2 after the procedure (p less than 0.0001), but there was a significant decrease to 0.67 +/- 0.19 cm2 at follow-up (p less than 0.05). Of patients free of aortic valve operation or death after 30 days after the procedure, 76% were severely symptomatic before the procedure as compared with 38% at follow-up. In patients undergoing percutaneous aortic balloon valvuloplasty, there is a continued high short-term mortality and a significant incidence of restenosis over short-term follow-up. Nonetheless, a subset of patients do experience sustained clinical improvement from this procedure.

Helium-Oxygen Gas Therapy: Use and Availability for the Emergency Treatment of Inoperable Airway Obstruction

Inoperable obstruction of the upper airway due to extrinsic malignancy may present as respiratory failure. We treated such a patient for 48 hours with 80 percent: 20 percent helium-oxygen delivered by a nonrebreathing mask while chemotherapy and radiation therapy reduced the tumor size. The need for intubation, mechanical ventilation, and high risk surgical intervention was avoided through the use of this gas therapy. We then surveyed San Francisco Bay area hospitals and found that fewer than one half could provide this potentially lifesaving gas therapy in an emergency situation. Physiologic basis of helium-oxygen gas therapy is reviewed and recommendations made for its use and availability.