Invasive Reoperation Research Articles

Abstract P1059: Decellularization Of Valved Porcine Xenografts For Use In Pediatric Right Ventricular Outflow Tract Replacement Surgery

Introduction: The right ventricular outflow tract (RVOT) is pathologically affected in multiple congenital heart diseases, requiring surgical replacement within the first year of life. Shortage of small-sized homografts has driven xenograft use in pediatric cardiac surgery. However, these RVOT substitutes do not possess lifelong durability, eliciting high levels of inflammation and lacking growth potential. Xenograft limitations culminate in structural graft deterioration and rejection, resulting in invasive reoperations. Decellularization of donor tissue to eliminate cells and immunogenic antigens is a central method by which rejection risk can be diminished. Maintenance of the extracellular matrix (ECM) must be balanced with achievement of acellularity. Currently, no xenograft has proven optimal for pediatric RVOT surgical replacement; this work aims to produce a resilient and non-immunogenic decellularized porcine scaffold with translational capacity. Methods/Results: Research sought to optimize a combined chemical, enzymatic, and mechanical decellularization approach for RVOT conduits. The nine-day protocol utilizes a temperature-controlled bioreactor wherein EDTA, protease inhibitors, sodium dodecyl sulfate, and nucleases are circulated through the lumen of the submerged conduit. Maintenance of ECM structure, including elastin and collagen, in parallel with significant nuclei count reduction, removal of residual nucleic acids, and elimination of xenoantigens has been achieved. No significant difference was found between control and decellularized ventricular soluble collagen. All comparisons between samples processed directly after explant (fresh) and those decellularized following one freeze-thaw cycle (freeze-thawed) were not significantly different. Conclusion: Data indicate successful decellularization of valved conduits. Future work intends to seed mesenchymal stem cells onto the cell-free scaffold, improving biocompatibility and endowing the xenograft with growth potential. Decellularized RVOT xenografts provide a means to combat immunological mismatch between donor and patient, reducing the number of surgeries a child is exposed to and improving pediatric congenital surgery outcome.

The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection.

A better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition. From 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups. Among weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly. Without increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.

Automatic detection of foreign body objects in neurosurgery using a deep learning approach on intraoperative ultrasound images: From animal models to first in-human testing.

Objects accidentally left behind in the brain following neurosurgical procedures may lead to life-threatening health complications and invasive reoperation. One of the most commonly retained surgical items is the cotton ball, which absorbs blood to clear the surgeon's field of view yet in the process becomes visually indistinguishable from the brain parenchyma. However, using ultrasound imaging, the different acoustic properties of cotton and brain tissue result in two discernible materials. In this study, we created a fully automated foreign body object tracking algorithm that integrates into the clinical workflow to detect and localize retained cotton balls in the brain. This deep learning algorithm uses a custom convolutional neural network and achieves 99% accuracy, sensitivity, and specificity, and surpasses other comparable algorithms. Furthermore, the trained algorithm was implemented into web and smartphone applications with the ability to detect one cotton ball in an uploaded ultrasound image in under half of a second. This study also highlights the first use of a foreign body object detection algorithm using real in-human datasets, showing its ability to prevent accidental foreign body retention in a translational setting.

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks.

Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66years. The median time to diagnosis of anastomotic leak was 10days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.

Tu1023 EFFICACY OF POLYGLYCOLIC ACID SHEETING WITH FIBRIN GLUE FOR GASTROINTESTINAL FISTULAS: A MULTICENTER RETROSPECTIVE STUDY

Anastomotic leakage, which is one of the complications of surgical operations, chemoradiation therapies (CRT) sometimes causes a refractory fistula despite conservative therapy, including local drainage and decompression of the digestive tract. Polyglycolic acid (PGA) sheets (Neoveil; Gunze, Kyoto, Japan) with fibrin glue (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) can be useful for closure of gastrointestinal fistulas, large-scale multicenter treatment outcomes have not been reported. Patients with GI fistulas endoscopically closed using PGA sheeting with fibrin glue between April 2013 and March 2018 in 18 institutions in the PGA study group, which is the affiliated study group of the Japanese Gastroenterological Endoscopy Society, were identifiedand retrospectively analyzed. Fistula is defined as the communication between the digestive tract and other areas (thoracic cavity, mediastinum, bronchus, abdominal cavity, etc.). Fistulas were filled with one or several pieces of PGA sheets followed by spraying fibrin glue using an endoscopic catheter. The procedure was repeated several times at 1- or 4-week intervals before fistula closure, and accompanied by nasal or percutaneous drainages, and endoscopic clipping as appropriate for each case. Fistula: Forty-five cases (hypopharyngeal/esophageal cancer 23, gastric cancer 5, colon cancer 4, and communicating organs: chest cavity 5, mediastinum 4, bronchus/lung 10/4, abdominal cavity 6, retroperitoneum 2, and others 14) were extracted. The median fistula diameter was 5 mm (range 1–20 mm). Thirty-six cases were related with operations; and 9, with other conditions, including CRT. PGA sheets were filled at a median of 2 times (range 1–10). Infections caused by fistulas were suspected in 12 cases (22%) because pus was observed in the fistulas. Percutaneous drainage was performed in 26 cases (58%); nasal drainage, in 14 (31%); and endoscopic clipping, in 16 (36%). Complete closure was attained in 25 cases (56%). The median period until resuming diet after starting sheeting was 16 days (range 1–222 days) in the closed cases. No statistically significant differences in fistula size, performance status, accompanying drainage, and the period between fistula occurrence and start of sheeting and fistula closure. The leak connected to bronchus/lung was significantly difficult to close compared with fistulas connected without bronchus (p=0.01). No statistically significant difference was observed in Albumin level (≧3.8, <3.8), but it was marginal factor for fistula closure (p=0.1). Eleven deaths occurred, which were not related to PGA sheeting adverse events. Endoscopic PGA sheeting can be expected to achieve conservative closure and inhibit highly invasive reoperation for more than half of fistula cases.Eventually the fistula was closed. The meal started on the 41st day after endoscopic PGA sheet filling was started.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Short-term outcomes of minimally invasive reoperation for tricuspid regurgitation after left-sided valve surgery

Objective: To examine the short-term outcomes of minimally invasive reoperation for severe tricuspid regurgitation after left-sided valve surgery. Methods: From January 2015 to December 2018, a total of 89 patients with severe tricuspid regurgitation after left-sided valve surgery received reoperation in Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University were included in this study. There were 21 males and 68 females, aging of (56.4±7.9) years (range: 41 to 74 years). The interval between previous left-sided valve surgery and tricuspid reoperation was (14.1±6.1) years (range: 4 to 33 years). A combination of multiple minimally invasive techniques were adopted, including endoscopy-assist right minithoracotomy approach, peripheral cannulation strategy with the vacuum-assist single venous drainage technique, heart beating technique, and temporary percutaneous pacemaker implantation, with a concomitant enhancement in preoperative right cardiac function optimization. Results: All patients received minimally invasive isolated tricuspid valve replacement (n=81) or tricuspid valve repair (n=8). After the application of multiple minimally invasive techniques, the operative mortality rate was only 3.4% (3/89). The causes of death were progressive right heart failure with multiorgan failure (n=1) and low cardiac output associated with postoperative bleeding (n=2). Regarding to the perioperative complications, renal replacement therapy rate was 5.6% (5/89), permanent pacemaker implantation rate was 1.1% (1/89), and the incidence of stroke was 0. Mechanical ventilation time was 24(24) hours, ICU stay time was 2.5 (3.0) days (M(Q(R))). During the short-term follow-up, there were no case of severe tricuspid regurgitation, 2 cases of moderate regurgitation, 4 cases of mild-to-moderate regurgitation. Conclusions: For severe tricuspid regurgitation after left-sided valve surgery, the advanced minimally invasive techniques can significantly reduce the operative mortality and morbidity. Minimally invasive bioprosthetic tricuspid valve replacement is a reliable alternative for severe tricuspid regurgitation after left-sided valve surgery.

Short- and long-term outcomes after colorectal anastomotic leakage is affected by surgical approach at reoperation.

Anastomotic leakage is the most serious surgical complication following colorectal resection, and surgical intervention is often required. The purpose of the study was to investigate short- and long-term outcomes after reoperation for anastomotic leakage. Patients with a symptomatic anastomotic leakage following a laparoscopic colorectal cancer resection from January 2009 to December 2014 were identified from our local prospective database. Patients were grouped according to the management of anastomotic leaks: local, lap, or open approach. Primary outcomes were length of stay, chance of bowel continuity, and overall mortality. A total of 113 patients were included. The median follow-up time was 40months (0-82months). Overall mortality was significantly associated with UICC stage III-VI disease (vs. UICC stage I-II disease) [adj. HR 5.35 (CI 2.32-12.4), p = 0.0001] and minimal invasive reoperation compared with open approach [local: adj. HR 0.12 (CI 0.03-0.52), p = 0.004; lap: adj. HR 0.32 (CI 0.12-0.86), p = 0.024]. Chance of bowel continuity was significantly increased in younger patients below 67years [adj. OR 6.15 (1.76-21.5), p = 0.004] and following a local procedure [adj. OR 7.45 (1.07-51.8), p = 0.043]. Patients in the open group had significantly longer length of stay and time to initiation of adjuvant chemotherapy compared with those in the lap group. Our data confirms that minimal invasive reoperation for anastomotic leakage is a safe and feasible approach associated with short- and long-term advantages and can be chosen in selected cases.

A different application of nuss procedure in a difficult case of pectus excavatum

A 17 year-old male patient who had a history of Nuss procedure 8 months ago with a diagnosis of pectus excavatum, the bar had been removed with left anterior thoracotomy due to complications such as bar dislocation, hemothorax and infection. Minimally invasive reoperation was performed on the patient who had an asymmetrical collapse distinctive on the right side. Classical Nuss operation was not possible due to strong adhesions that developed after past procedures. At this point, instead of open surgery, we entered the thoracic cavity with two new incisions performed on the two peak points of the collapse. A tunnel was formed beneath the sternum with obtuse and sharp opposing dissections through the newly formed holes. Subsequently, subcutaneous tunnels were opened up to the new entry holes through the initial incisions that were formed left and right previously. The bar was swiped under the sternum and rotated by using the subsequent holes as entry and exit holes for the bar. It was immobilized with a stabilizer. No complications occurred in the postoperative period. Pleural adhesions are accepted as one of the most important contraindications of thoracoscopic surgery. Nevertheless, with the help of two incisions in addition to the main procedure we present our case of re-operated pectus excavatum with a minimally invasive procedure and a successful outcome.

Local Resection by Combined Laparoendoscopic Surgery for Duodenal Gastrointestinal Stromal Tumor

Combined laparoendoscopic surgery is a novel surgical method which consists of both endoscopic surgery from inside the gastrointestinal tract and laparoscopic surgery from the outside. We report a case of duodenal GIST, in which combined laparoendoscopic local resection was attempted. The lesion was resected endoscopically using endoscopic submucosal dissection technique under laparoscopic assistance. Laparoscope was used for originating the orientation of the tumor, intra-operative EUS, and monitoring serosal injury from the peritoneal cavity. Postoperative hemorrhage occurred; however, precise orientation of the lesion helped us to manage the patient with minimal invasive reoperation. And thus, the bowel integrity was completely preserved, by avoiding segmental duodenal resection and pancreaticoduodenectomy. This novel, less invasive surgical procedure may become an attractive option for the lesions originating in the anatomically challenging portion of the GI tract for endoscopic or laparoscopic surgery alone.

Retrospective review of reoperative pectus excavatum repairs

Background/Purpose Despite success of several techniques described for pectus excavatum repair, a minority of patients require multiple reoperations for recurrence or other complications. We aimed to review our experience in reoperative pectus excavatum repairs and to identify features correlating with need for additional reoperations. Methods Charts were reviewed of all patients undergoing reoperative pectus excavatum repair for 3 years at a university-based children's hospital. Number and type of previous repairs, time between operations, lengths of stay, analgesia, and complications were recorded. Results From February 2004 to December 2007, 170 pectus excavatum repairs were performed. Among these, 27 were reoperative. Overall, 18.2% of reoperative patients required subsequent additional reoperations. 21.1% of patients undergoing repeat open repairs and 33.3% of patients undergoing repeat minimally invasive repairs required further operative interventions. There was no need for additional repairs among patients who had open repairs after minimally invasive repairs, nor for any patients who had minimally invasive repairs after open repairs. Conclusions We conclude that patients with failed open repairs will have better success with minimally invasive reoperations, whereas patients with failed minimally invasive repairs will have better success with open reoperations. When faced with reoperative pectus excavatum, we recommend consideration of an alternative operative approach from the initial procedure.

Natural Orifice Management of Anastomotic Leaks After Minimally Invasive Esophagogastrectomy

A leak after an esophagectomy can lead to significant morbidity and mortality. The treatment options for postoperative leaks include reoperation with pleural drainage and placement of T-tube drainage catheter to control the gastrointestinal leak or complete gastrointestinal diversion, depending on the extent of the leak and tissue viability of the gastric conduit. Both these options require an invasive reoperation. In selected cases, endoscopic deployment of a covered esophageal stent may be an effective minimally invasive option in the management of an esophageal leak. This report describes the indications and techniques for management of an esophageal leak using the natural orifice for drainage of a mediastinal abscess and deployment of an esophageal stent.

Minimally Invasive Reoperation following Laparotomy

The surgical indications for laparoscopic techniques continue to expand as experience is gained. This includes patients who have had a previous open abdominal operation and require surgical intervention. In addition to the generally accepted indications for laparoscopy, conditions such as reversal of colostomy, small bowel obstruction, and early reoperation for surgical complications may be managed using minimally invasive techniques. Specific considerations in this group of patients include peritoneal access and establishing domain, lysis of adhesions, and situations that should prompt conversion.

Outcomes after minimally invasive reoperation for gastroesophageal reflux disease

Background. Reoperative antireflux surgery is complex and traditionally performed by open methods. Increasingly, surgeons are performing minimally invasive reoperations. This report summarizes our experience with laparoscopic reoperative antireflux surgery (LRAS). Methods. A retrospective review (1996 to 2001) identified 80 LRAS cases. Median age was 49 (22 to 80) years with 52 females and 28 males. Primary symptoms included heartburn (53%), regurgitation (22%), and dysphagia (25%). Detailed outcomes recorded at follow-up included heartburn severity using the Gastroesophageal Reflux Disease-Health Related Quality of Life scale (HRQOL) and SF36 physical (PCS) and mental (MCS) component summary scores. Results. LRAS was completed in 97.5% of cases (two conversions). The most common problems identified were mediastinal migration of the wrap in 48 (60%) and misplaced wrap in 11 (13.8%). LRAS operations included Collis-Nissen (42), Nissen (26), Toupet (six), and six others. Pyloroplasty was required in nine (11%). Complications occurred in 16 patients. These included nine minor gastric perforations (all repaired intraoperatively) and two reoperations for complications (1 patient with a bile leak and the second with a pyloroplasty site leak). Median length of stay was 2.5 days. Median follow-up was 18 (1 to 52) months; 18 (23%) required proton-pump inhibitors. Detailed outcomes were available in 50 patients. Mean PCS and MCS scores were 42 and 47, respectively (normals = 50). HRQOL scores were excellent in 35 (65%), satisfactory in 9 (17%), and poor in 10 (18%). Ten patients (18%) reported that they were dissatisfied. Conclusions. LRAS can be performed safely with complication and success rates similar to open operations in a center with extensive laparoscopic experience.