Initial Surgical Experience Research Articles

Rectovaginal Fistula Repair Using a Disposable Biopsy Punch

To describe a novel surgical technique for complete excision of a rectovaginal fistula tract using a disposable biopsy punch during a transvaginal rectovaginal fistula repair and to present our initial surgical experience. Description of 4 cases of simple rectovaginal fistulas and an innovative surgical technique for the complete excision of the fistula tract using a disposable biopsy punch. Successful 3-, 9-, and 12-month follow-up of 4 cases with simple rectovaginal fistulas after transvaginal rectovaginal fistula repair using a novel approach for complete fistula tract excision with a disposable biopsy punch and layered nonoverlapping suture closure. Demographic information reported included age, parity, medical and surgical history, as well as fistula characteristics including size, location, presenting symptoms, and duration of symptoms. We describe our operative technique with picture description. This novel approach using a disposable punch biopsy device to complete excision of simple rectovaginal fistula tracts during a transvaginal rectovaginal fistula repair can help with achieving a successful surgical outcome.

Comparison of the initial surgical experience with robotic and laparoscopic myomectomy

To compare the initial surgical outcomes of robotic and laparoscopic myomectomy in patients with symptomatic uterine myomas. Retrospective chart review of 86 patients undergoing robotic (RM) (n = 43) or laparoscopic (LM) (n = 43) myomectomy. Data included fibroid characteristics (number, weight, location) layers of uterine reconstruction, operating time, blood loss, complications, and postoperative hospital stay. No significant differences were noted between RM and LM for fibroid number and weight and mean operating time, although the number of patients receiving at least a double-layer uterine reconstruction was higher in RM than LM. Blood loss was higher after LM, while no differences resulted in hospital stay. RM may have some additional advantages compared with LM in terms of bleeding and uterine suturing without compromising operation duration, at least when surgeons were at the beginning of their experience of endoscopic treatment of symptomatic uterine myomas.

Laparoendoscopic Single-Site Partial Nephrectomy Without Ischemia

Nephron-sparing surgery (NSS) ensures excellent oncologic and functional outcomes in small renal masses. Laparoendoscopic single-site surgery (LESS) is one of the major advances in the evolution of minimally invasive surgery. We describe our initial surgical experience and assess the feasibility of LESS unclamp-NSS. From April to September 2009, all consecutive patients with solitary, exophytic, enhancing, small (≤4.0 cm) renal masses and normal contralateral kidney were selected to receive LESS unclamp-NSS. A multichannel port provided intra-abdominal transperitoneal access. Rigid and articulable instruments were used for dissection, tumor exposure, and excision under normal renal perfusion. Perioperative, pathologic, hematologic data together with a subjective evaluation of pain and scar were collected and evaluated. Six patients underwent LESS unclamp-NSS (mean operative time, 148 min; mean blood loss, 201 mL; mean renal masses size, 2.1cm). One patient needed conversion to standard laparoscopy because of excessive bleeding. Postoperatively, a cerebrovascular accident developed in one patient. No transfusion was necessary. Pathologic examination revealed two clear-cell carcinoma, three benign cysts, and one angiomyolipoma (surgical margin positive). A 2.7 g/dL hemoglobin level decrease was recorded with minimal pain and great patient satisfaction. Mean length of stay was 6 days. LESS unclamp-NSS in selected renal masses is feasible, provides postoperative outcomes overlapping the standard counterpart, and ensures subjective satisfaction. Additional trocars should be considered for the hemostatic stitches and for liver retraction. A wider experience and longer follow-up are necessary to establish the role of this technique.

Transitioning to Optimized Correction with the WaveLight ALLEGRETTO WAVE: Case Distribution, Visual Outcomes, and Wavefront Aberrations

To describe the outcomes of the first 285 eyes receiving LASIK or photorefractive keratectomy (PRK) using an optimized ablation profile at a refractive surgery practice experienced with customized ablation. A retrospective chart review was performed on all patients who underwent refractive treatments using the ALLEGRETTO WAVE Eye-Q platform (Alcon Laboratories Inc) between September 2008 and July 2009. Patients were divided into LASIK and PRK treatments, then further subdivided based on pre- and targeted postoperative refraction. Pre- and postoperative measures of uncorrected distance visual acuity (UDVA), corrected distance visual acuity, manifest refraction, keratometry, and wavefront values were taken and compared, and the average changes in keratometry and higher order aberrations were calculated. At 3 months postoperative, 92% of myopes and 63% of hyperopes undergoing LASIK with a target of emmetropia achieved UDVA of 20/20. Of PRK eyes targeted for emmetropia, 80% of myopic eyes achieved UDVA of 20/20 (the hyperopic subgroup was too small to analyze). In both LASIK and PRK subgroups, total wavefront aberrations decreased, as did some higher order aberrations. This group of patients, who all achieved excellent postoperative UDVA, represents our initial surgical experience with the ALLEGRETTO WAVE, using only a standard (global surgeon) nomogram. These results may serve as an estimate of what a practice could expect in terms of initial outcomes with this system.

Robotic Versus Laparoscopic Partial Nephrectomy: Single-surgeon Matched Cohort Study of 150 Patients

To present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. Between March 2002 and August 2009, a retrospective review of 261 consecutive patients who underwent LPN (n = 186) or RPN (n = 75) by a single surgeon was performed. Patients were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and tumor size, side, and location. Perioperative outcomes were compared. A matched cohort of 150 patients who underwent RPN (n = 75) or LPN (n = 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (P = .17), BMI (P = .68), ASA score (P = .96), preoperative estimated glomerulofiltration rate (eGFR; P = .54), or tumor size (P = .17). Mean operative time for RPN was 200 vs 197 minutes for LPN (P = .75). Mean estimated blood loss (EBL) was higher in the RPN cohort (323 vs 222 mL, P = .01). There was no significant difference with respect to warm ischemia time (18.2 minutes vs 20.3 minutes, P = .27), length of hospitalization (P = .84), percent change in eGFR (P = .80), or adverse events (P = .52). All surgical margins were negative. Although initial surgical experience with RPN was included in this study and compared with a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN.

Initial Resident Refractive Surgical Experience: Outcomes of PRK and LASIK for Myopia

To evaluate and compare the outcome of initial resident surgical experience with photorefractive keratectomy (PRK) and LASIK. Retrospective review of all cases performed with the VISX Star S4 platform (Abbott Medical Optics) between July 1, 2003 and June 30, 2007. Inclusion criteria were spherical equivalent of -0.50 to -10.00 diopters (D), refractive astigmatic error of ≤3.00 D, intention to provide full distance correction, and minimum 3-month postoperative follow-up after initial ablation or retreatment (if performed). A total of 153 cases performed by 20 different residents met the inclusion criteria; 38 eyes underwent PRK and 115 eyes had LASIK. After initial treatment, mean Snellen uncorrected distance visual acuity (UDVA) after PRK was 20/17.3 and after LASIK was 20/19.5. Photorefractive keratectomy was associated with a significantly better approximation between preoperative corrected distance visual acuity (CDVA) and postoperative UDVA (ΔlogMAR 0.009 vs 0.091; P=.004) and a greater percentage of eyes that achieved UDVA of 20/20 or better (94.7% vs 78.3%; P=.02) or 20/30 or better (100% vs 87.8%; P=.02). There was a higher prevalence of retreatment in eyes that underwent LASIK (7.0% vs 0%; P=.20). One (0.9%) eye lost 2 lines of CDVA after LASIK. Supervised refractive surgery residents can achieve excellent visual outcomes in patients operated during their initial refractive experience. Photorefractive keratectomy was associated with better visual outcome than LASIK.

909 ROBOTIC VERSUS LAPAROSCOPIC PARTIAL NEPHRECTOMY:

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010909 ROBOTIC VERSUS LAPAROSCOPIC PARTIAL NEPHRECTOMY: Georges-Pascal Haber, Wesley M. White, Rakesh Khanna, Michael A. White, Riccardo Autorino, Sebastien Crouzet, Sylvain Forest, and Jihad H. Kaouk Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Wesley M. WhiteWesley M. White More articles by this author , Rakesh KhannaRakesh Khanna More articles by this author , Michael A. WhiteMichael A. White More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Sebastien CrouzetSebastien Crouzet More articles by this author , Sylvain ForestSylvain Forest More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1665AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. METHODS Between March 2002 and August 2009, a retrospective review of medical charts of 261 consecutive patients who underwent LPN (n=186 ) or RPN (n=75) by a single surgeon (JHK) was performed. Patients were matched for age, gender, body mass index (BMI), ASA score, and tumor size, side, and location. Perioperative outcomes of both groups were compared. RESULTS A matched Cohort of 150 patients who underwent RPN (n = 75) or LPN (n = 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (p = 0.17), BMI (p = 0.68), ASA score (p = 0.96), preoperative eGFR (p = 0.54), or tumor size (p = 0.17). Mean operative time for RPN was 200 minutes versus 197 minutes for LPN (p = 0.75). Mean EBL was higher in the RPN cohort (323mL vs 222mL, p = 0.01). There was no significant difference between the 2 cohorts with respect to warm ischemia time (18.2 min vs 20.3min, p = 0.27), length of hospitalization (p = 0.84), % change in eGFR (p = 0.80), or adverse events (p = 0.52). All surgical margins were negative. CONCLUSIONS Although initial surgical experience with RPN was included in this study and compared to a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN with the potential of improved outcomes as experience in RPN accumulates. Cleveland, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e355 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Georges-Pascal Haber More articles by this author Wesley M. White More articles by this author Rakesh Khanna More articles by this author Michael A. White More articles by this author Riccardo Autorino More articles by this author Sebastien Crouzet More articles by this author Sylvain Forest More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Evaluation of laparoscopic sleeve gastrectomy on weight loss and co-morbidity

Background The sleeve gastrectomy is a surgical technique to treat morbid obesity by both restrictive and probably hormonal action. Originally developed as a first stage to gastric bypass, it is more and more performed as a sole procedure. Therefore it is important to report results on weight loss and reduction in co-morbidity. Methods A consecutive series of 74 morbid obese patients were evaluated. Parameters were operative variables, complications, weight loss and the need for medication for co-morbidity at least six months postoperatively. Results Six procedures included the removal of a band and twice a vertical banded gastroplasty was performed previously. Median operating time diminished over time to 71 min. Three procedures were converted into open approach. Major complications were rhabdomyolysis (2), bleeding (2) and leakage (4). Four days was the mean hospital stay. The median follow-up was 12 months (range 6–33). The median percentage of excess weight loss was 49.6% (range 22–96%EWL). The median loss in BMI points was 23.1% (range 9–50%BMIL). Three quarters of the patients were able to diminish or stop their medication for diabetes, hypertension and hyperlipedemia. Conclusion The laparoscopic gastric sleeve is effective in reduction of both weight and co-morbidity and has potential as a sole procedure. Patient’s selection is, however, recommendable for initial surgical experience and longer follow-up will be necessary.

Initial Surgical Experience Evaluating Early Tolerance and Toxicities in Patients Undergoing Accelerated Partial Breast Irradiation Using the Contura® Multi Lumen Balloon Breast Brachytherapy Catheter

We reviewed our surgical experience with the Contura Multi Lumen Balloon breast brachytherapy catheter used to deliver accelerated partial breast irradiation and determined short-term treatment efficacy, cosmesis, and toxicity. Forty-six patients undergoing breast conserving therapy, including the use of Contura catheter, were analyzed. Thirty-four Gray were delivered in 10 fractions. Fourteen patients had stage 0, 24 had stage I, and 8 had stage II breast cancer. Catheters were placed with a closed cavity technique. Median minimum skin spacing was 10 mm (range, 2-18 mm). Median maximum skin doses were 99.7 per cent of the prescription dose. Nine patients were treated with a skin spacing < or = 5 mm (2 patients with 2 mm skin spacing). The percentage of patients with excellent/good cosmesis at 6 (n = 26) and 12 (n = 13) months was 100 per cent, respectively. Patient tolerance was assessed on a scale of 0-10 (0 = no pain, 10 = requiring narcotic analgesics). Pain was graded < or = 3 in 98 per cent of patients at catheter insertion and 84 per cent at catheter removal. Four breast infections (8.8%) and one symptomatic seroma developed. Adjuvant accelerated partial breast irradiation using the Contura Multi Lumen Balloon exhibited similar toxicities to standard single lumen, single dwell balloon brachytherapy with improvements in dosimetric capabilities allowing the treatment of patients with skin spacing < or = 5 mm.

Initial surgical experience in laparoscopic total mesorectal excision for middle and lower third rectal cancer: short-term results

Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy. To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients. One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered. In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo- anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3+/-38.3 min and mean blood loss was 215+/-180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3+/-2.2 cm. Nodal sampling of 12.4+/-4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method). Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe.

INITIAL SURGICAL EXPERIENCE WITH A DENSE CORTICAL MICROARRAY IN EPILEPTIC PATIENTS UNDERGOING CRANIOTOMY FOR SUBDURAL ELECTRODE IMPLANTATION

Detailed investigations of cortical physiology require the ability to record brain electrical activity at a submillimeter scale. Standard intracranial electrodes result in significant averaging of potentials generated by large numbers of neurons. In contrast, microelectrode arrays allow for recording of local field potentials and single-unit activity. We describe our initial surgical experience with the NeuroPort microelectrode array (Cyberkinetics Neurotechnology Systems, Inc., Salt Lake City, UT) in a series of patients undergoing subdural electrode implantation for epilepsy monitoring. Seven patients were implanted with and underwent semichronic recording from the NeuroPort array during standard subdural electrode monitoring for epilepsy. The electrode was placed according to company specifications in putative noneloquent epileptogenic cortex. After the monitoring period, microelectrode arrays were removed during explantation of subdural electrodes and resection of epileptogenic tissue. Successful implantation of the microelectrode array was achieved in all patients, with minor operative difficulties. Robust and durable local field potentials and single-unit recordings were obtained from all implanted individuals. Implantation times ranged from 3 to 28 days; histological analysis of implanted tissue demonstrated no significant tissue injury or inflammatory response. There were no neurological complications or infections associated with electrode implantation or prolonged monitoring. Two patients developed postresection issues with wound healing at the site of scalp egress, with 1 requiring operative wound revision. Our experience demonstrates that semichronic microelectroencephalographic recording can be safely and effectively achieved using the NeuroPort microarray. Although significant tissue injury, infection, or cerebrospinal fluid leak was not encountered, the large profile of the connection pedestal resulted in suboptimal wound closure and healing in several patients. We predict that this problem will be easily addressed in second-generation devices.

Comparison of Initial Surgical Outcomes between Laparoscopic Radical Prostatectomy and Robot-Assisted Laparoscopic Radical Prostatectomy Performed by a Single Surgeon

Purpose: Pure laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP) are less invasive alternative techniques for localized prostate cancer. We report our initial surgical experience of LRP and RALP performed by a single surgeon. Materials and Methods: Between October 2007 and August 2008, 31 and 21 patients were treated with LRP and RALP by the same surgeon, respectively, and both groups were similar in preoperative clinical parameters, including serum prostate-specific antigen (PSA) level, Gleason score (GS), and clinical stage. We analyzed the perioperative parameters and early short-term surgical outcome of LRP and RLRP by retrospective chart review. Results: The mean surgical times for LRP and RALP were 279 and 337 min, respectively, and other perioperative data showed no significant differences between the 2 groups (all p>0.05) with the exception of the preservation rate of neurovascular bundles (58% LRP and 95% RALP, p=0.008). The pathologic parameters including the positive surgical margin rate of the 2 groups were comparable (29% LRP and 29% RALP, p>0.05). Immediately and at 1 month after catheter removal, the RALP group showed a better continence rate than did the LRP group (all p<0.05), but the overall continence rate was similar (80.6% LRP and 81% RALP, p=1.00). Operative charges for RALP were almost 9.4 times as high as those for LRP (p=0.03). Conclusions: We found comparable efficacy and safety of LRP and RALP for localized prostate cancer in this study. Although RALP showed a better short-term continence rate, LRP was analyzed as being the more costeffective procedure. (Korean J Urol 2009;50:468-474) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Initial Surgical Experience with an Intracortical Microelectrode Array for Brain-computer Interface Applications

Initial Surgical Experience with an Intracortical Microelectrode Array for Brain-computer Interface Applications

Initial Surgical Experience with an Intracortical Microelectrode Array for Brain-computer Interface Applications

Initial Surgical Experience with an Intracortical Microelectrode Array for Brain-computer Interface Applications

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES AFTER CONCENTRATED TRAINING IN UROLOGICAL LAPAROSCOPY

To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.

Ligadura videotoracoscópica da persistência do canal arterial

OBJETIVO: Demonstrar a técnica de fechamento da Persistência do Canal Arterial (PCA), destacando a simplicidade e singularidade do método. CASUÍSTICA E MÉTODO: No período de março de 1994 a novembro de 1999, 40 pacientes (pac), com idade entre 8 meses e 17 anos e predominando o sexo masculino, foram submetidos a operação de fechamento da PCA através de videotoracoscopia. O paciente é colocado em decúbito lateral direito, sob anestesia geral com intubação seletiva do pulmão direito. São usados quatro trocateres: um de 3 mm no 3º espaço intercostal (EIC) esquerdo na linha axilar anterior e outro trocater de 5 mm no 3º (EICE) na linha axilar média. A ótica 30 graus infantil é introduzida em um trocater de 3 mm no 5º EICE na linha axilar posterior e outro trocater de 5 mm no 5º EICE na linha axila anterior. A identificação do canal é feita tendo como parâmetro anatômico os nervos frênico e vago. Após o isolamento, o canal é duplamente clipado ou ligado com fio de algodão grosso com nó interno. Terminado o procedimento, o pulmão é expandido sob visão direta, não havendo necessidade de drenar o tórax. RESULTADOS: Obtivemos sucesso inicial em 37 pac (92,5%), sendo necessária reversão para operação convencional em 3 pac (7,5%). Não houve óbito nem complicações e o tempo médio de hospitalização foi de 48 horas. CONCLUSÃO: Acreditamos ser o procedimento eficaz, seguro, com pequeno índice de complicações, custo baixo e uma curva de aprendizado também pequena.

Experiência cirúrgica inicial com a operação de Ross (auto-enxerto pulmonar)

FUNDAMENTO: Em decorrencia dos excelentes resultados tardios observados com a operacao de Ross, sua utilizacao tem sido cada vez mais frequente em varios Centros de todo o mundo. OBJETIVO: Relatar a experiencia cirurgica inicial com essa operacao em nosso meio. CASUISTICA E METODOS: De maio/95 a fevereiro/96,24 pacientes com media de idades de 28,3 anos foram submetidos a operacao de Ross pelo metodo de substituicao do segmento proximal da aorta ascendente. Para a reconstrucao da via de saida do ventriculo direito, foram utilizados 17 homoenxertos pulmonares e 7 homoenxertos aorticos preservados em solucao de antibioticos. Em todos os pacientes foram realizados ecocardiograma bidimensional com Doppler e cateterismo cardiaco no pos-operatorio imediato, para avaliar a funcao ventricular e desempenho hemodinâmico dos auto e homoenxertos utilizados. Tres pacientes com evolucao clinica superior a seis meses realizaram novo ecocardiograma. RESULTADOS: A mortalidade hospitalar foi de 4%. Os sobreviventes tiveram alta hospitalar em ritmo sinusal e sem sopro diastolico de insuficiencia aortica. O desempenho hemodinâmico dos auto-enxertos foi muito satisfatorio, com baixos gradientes de pico (4,0 ± 1,3 mmHg pelo ecocardiograma e 2,8 ± 1,2 mmHg pelo cateterismo). Vinte e um pacientes apresentaram auto-enxertos suficientes e/ou com insuficiencia trivial, e 2 pacientes tiveram insuficiencia leve. Nenhum paciente teve insuficiencia moderada ou importante. Os gradientes de pico dos homoenxertos tambem foram baixos (3,0 ± 0,9 mmHg pelo ecocardiograma e 4,3 ± 1,4 mmHg pelo cateterismo) e apenas 2 apresentaram insuficiencia leve. Houve significativa reducao das dimensoes sistolica e diastolica do ventriculo esquerdo no pos-operatorio imediato, assim como da massa ventricular esquerda. Apos um tempo medio de seguimento clinico de 5,1 meses (1-9 meses), todos os pacientes encontram-se em classe funcional I e livres de eventos. Tres pacientes, com tempo de evolucao superior a seis meses, realizaram ecocardiograma, que demonstrou normalizacao da funcao e massa ventricular, assim como manutencao do adequado desempenho hemodinâmico dos enxertos. CONCLUSOES: A operacao de Ross pode ser realizada em nosso meio com baixa mortalidade e resultados satisfatorios a curto prazo. Acreditamos que sera amplamente empregada.

Surgical management of aortopulmonary septal defect

Fourteen patients with malseptation of the aortopulmonary trunk underwent operative repair from 1978 to 1988. Age ranged from 1 year to 35 years (mean age, 9.6 years). Five patients had type I, 6 had type II, and 3 had type III lesions. The hemodynamic disturbance in all patients was the consequence of a large left-to-right shunt (mean pulmonary/systemic flow ratio, 2.38:1) with increased pulmonary vascular resistance (mean value, 4.47 units/ m 2). Our initial surgical experience with closure under cardiopulmonary bypass through the transaortic route in 3 patients and the transpulmonary approach in two patients resulted in 3 deaths. In the 9 subsequent patients, division and repair of the defect in the great vessels yielded uniformly good results. During followup, which ranged from 3 months to 2 years, all 11 survivors had good clinical improvement and none showed residual defects on restudy. Pulmonary artery pressure and pulmonary vascular resistance decreased in all patients except 1.

Automatic defibrillation in man: The initial surgical experience

The automatic implantable defibrillator is an electronic device designed to detect and promptly correct malignant ventricular arrhythmias. Nineteen patients, all survivors of multiple cardiac arrests because of ventricular arrhythmias unresponsive to therapy, have undergone implantation of the automatic defibrillator. In seven patients who had had a previous cardiac operation, implantation was performed through a left lateral thoracotomy. A median sternotomy was used in five patients without a previous operation. In six patients cardiac procedures were performed concomitantly with defibrillator implantation. There were no operative deaths. The average follow-up is 6 months, the longest being 14 months. Following implantation, 47 episodes of malignant ventricular arrhythmias were documented. Twenty-six occurred spontaneously (17 of them outside the hospital); all were corrected with a single 25 joule pulse. Seventeen of 21 arrhythmias induced postoperatively were terminated. Although further validation is required, this study demonstrates that the automatic defibrillator is capable of diagnosing and terminating potentially lethal ventricular arrhythmias. Finally, implantation can be safely accomplished in an exceedingly high risk population.

Main left coronary artery disease. Clinical experience from 1964-1974.

Obstructive lesions of the main left coronary artery (LCA) were demonstrated angiographically in 73 patients, comprising 4.3% of the total population referred to us for diagnostic evaluation of chest pain. Although there were no specific historical or clinical features which could absolutely distinguish this subgroup from the larger population of coronary artery disease patients, 81% (34/42) of the double Master's exercise tests, in which the patient achieved a heart rate of at least 110 beats/min. demonstrated greater than or equal 2 mm R-ST segmental depression. Of the total group of 73, 32 were evaluated during the six-year period from 1964 to 1971 and a preliminary report made in 1972. The diagnosis in the remaining 41 patients was established in the 1/2 year period from 1971 to 1973. The initial 32 patients were seen before the significance of a main LCA lesion was appreciated. In this subgroup there were five deaths at the time of cardiac catheterization. However, in the more recent group improved recognition of patients with possible main LCA disease prior to catheterization has led to a much lower death rate related to diagnostic catheterization. Only one of the last 41 patients undergoing coronary angiography has died. Nineteen patients were managed medically. Of this group 17 were considered to be under the same risk of death as the surgical candidates. Their mortality rate, as high. The risk of hying was 43.6% after 24 months, 51.1% after 36 months, and 73.6% after 42 months of observation. Although the initial surgical experience, using internal mammary artery implants and saphenous venin bypass grafts, was associated with a high mortality, direct revascularization surgery over the last 2 1/2 years has been accomplished with a perioperative mortality of only 6.2%. All deaths in the group of 40 patients receiving elective revasularization with saphenous vein bypass grafts occurred in the first six months following surgery. The risk of dying was 12.5% after six months of observation and was unchanged for the remainder of the follow-up period. After 21 months the difference in survival between the two groups is statistically significant (P less than 0.05). The one late death among the surgical survivors occurred four months after the operative procedure and was related to noncardiovaxcular surgical complications. The surgical survivors have been followed for an average of 27 months. Thus revascularization surgery has improved the prognosis for patients with main LCA disease. We currently advise prompt evaluation for any patient suspected of having this type of obstruction and urgent idrect revascularization surgery if this lesion is demonstrated angiographically.