Operative Deaths Research Articles

Impact of Surgery Timing and Malperfusion on Acute Type A Aortic Dissection Outcomes.

To determine the impact of symptom-to-surgery time on mortality in acute type A aortic dissection (ATAAD) patients, with and without malperfusion. A retrospective analysis of 288 ATAAD patients was conducted. Patients were separated into the early (≤ 10 h) and late (> 10 h) groups by symptom-to-surgery time. Data on characteristics, surgery, and complications were compared, and multivariable logistic regression determined mortality risk factors. Mortality rates did not significantly differ between early and late groups. Age (OR 1.09, 95% CI 1.05-1.13, p<0.001), ECMO use (OR 10.73, 95% CI 2.51-45.87, p=0.001), and malperfusion (OR 6.83, 95% CI 2.84-16.45, p<0.001) predicted operative death. Subgroup analysis showed cerebral (OR 3.20, 95% CI 1.11-9.26, p=0.031), cardiac (OR 5.89, 95% CI 1.32-26.31, p=0.020), and limb (OR 6.20, 95% CI 1.75-22.05, p=0.005) malperfusion as predictors of operative death. One (OR 6.30, 95% CI 2.39-16.61, p<0.001), two (OR 12.79, 95% CI 2.74-59.81, p=0.001), and three (OR 46.99, 95% CI 7.61-288.94, p<0.001) organs malperfusion, together with Penn B (OR 7.96, 95% CI 3.04-20.81, p<0.001) and Penn B-C (OR 12.50, 95% CI 2.65-58.87, p=0.001) classifications predict operative mortality. Survival analysis revealed significant differences between malperfusion and no malperfusion (34% vs. 9%, p<0.001) but not between late and early (14% vs. 21%, p=0.132) groups. Malperfusion remained an essential predictor of operative (OR 7.06 95% CI 3.11-17.19, p<0.001) and mid-term mortality (OR 3.38 95% CI 1.97-5.77, p<0.001) in subgroup analysis. Preoperative malperfusion status, rather than symptom-to-surgery time, significantly impacts both operative and mid-term mortality in ATAAD patients.

A retrospective study on safety and efficacy of recombinant human soluble thrombomodulin to acute aortic dissection with disseminated intravascular coagulation

ObjectivesRecombinant human soluble thrombomodulin (rTM) has recently been used as a promising therapeutic natural anti-coagulant drug for disseminated intravascular coagulation (DIC). Here we investigated the safety and efficacy of rTM after aortic surgery in patients with acute aortic dissection (AAD).MethodsA total of 316 patients diagnosed with AAD underwent emergent ascending aortic replacement or total arch replacement between 2010 and 2019. We retrospectively analyzed the clinical information of 62 patients with the Japanese Association for Acute Medicine’s acute-stage DIC diagnostic criteria (JAAM criteria) with a score of ≥ 4. We assigned 62 patients to two groups, either non-rTM group (n = 29) or rTM group (n = 33). Patient characteristics, surgical procedures, and postoperative outcome data including coagulation function and the JAAM DIC score in both groups were collected.ResultsThe decrease in the number of platelets was clearly suppressed on days 1–3 in the rTM group. On days 1–4, fibrin degradation product levels were upregulated in the non-rTM group but significantly downregulated in the rTM group. Five operative deaths occurred within 30 days postoperative (two [6.9%] in the non-rTM group vs. three [9.1%] in the rTM group). The JAAM DIC score showed a gradually improving trend from postoperative day 1 in the rTM group.ConclusionsPostoperative rTM administration for AAD may be a safe and promising novel treatment strategy for improving the JAAM DIC score.

Impact of Covert Brain Infarction Following Coronary Angiography on Coronary Artery Bypass Surgery Outcomes

ObjectiveTo determine the association between preoperative covert brain infarction following coronary angiography (CAG) and major adverse cardiac and cerebrovascular events (MACCE) after CABG. DesignCohort study between January 2006 and December 2019 with the follow-up period concluding at either 5 years after surgery, the date of death, or April 27th, 2023. SettingAt a single tertiary center in Korea. ParticipantsPatients who underwent pre-operative CAG and subsequent brain magnetic resonance imaging (MRI) before elective CABG. InterventionsNone. Measurements and Main ResultsThe primary outcome was the incidence of MACCE within 30 days of CABG. MACCE included operative death (all-cause death within 30 days of surgery or before discharge), myocardial infarction, mechanical circulatory support, circulatory arrest, and stroke. The secondary outcomes included each component of MACCE and all-cause mortality at 5 years after surgery. Out of the 2,476 study patients (median [IQR] age, 65 [58 to 71] years; 24.7% were female), 212 (8.6%) had covert cerebral infarction on brain MRI after CAG but before CABG, and 353 (14.3%) patients experienced MACCE after CABG. After performing 1:4 propensity-score matching, a total of 1,057 patients were included in the final outcome analysis (212 with covert brain infarction and 845 without). The incidence of MACCE within 30 days was not significantly different between patients with a covert brain infarction and those without (15.1% [32/212] vs. 15.6% [132/845]; risk difference, -0.5, 95% confidence interval [CI]: -5.6 to 4.4; risk ratio: 0.97, 95% CI, 0.66 to 1.32; P=.85). There were also no significant differences in each component of MACCE within 30 days. There was no significant difference between the two groups in terms of all-cause mortality at 5 years (18.7% vs. 17.0%, respectively, P for stratified log-rank test=.33). ConclusionsAmong patients undergoing elective CABG, there was no significant association between covert brain infarction following CAG and the occurrence of MACCE within 30 days and long-term mortality after CABG.

A clinical comparison of glycol and water-based heater-cooler systems for cardiopulmonary bypass.

While newer heater-cooler technologies using ethylene glycol-based (GB) solutions during cardiothoracic surgery have become commercially available, there is a paucity of clinical data describing their effectiveness during cardiopulmonary bypass (CPB) support. This analysis aimed to compare clinical characteristics and procedural outcomes using water-based (WB) and GB heater-cooler systems. A retrospective analysis was performed on consecutive adult patients undergoing CPB from June to October 2022 comparing WB or GB groups. The primary outcome was a composite of operative death or major morbidity. Secondary endpoints included transfusion requirements on CPB, patient cooling and warming rates, and vasoactive-inotropic scores (VIS) at case completion. P-control charts were used to monitor the weekly incidence of the composite outcome. A sub-analysis was performed to evaluate the primary outcome for cardiac surgery cases indexed by the Society of Thoracic Surgeons (STS). There were 167 patients included for analysis; 87 (52.1%) underwent CPB with a WB system and 80 (47.9%) with a GB system. GB procedure subjects were younger (p = .01), experienced longer CPB times (p = .034), and were more likely to receive thoracic transplant or aortic surgery (p = 0.015). The composite outcome of operative mortality or major morbidity occurred in 29.9% and 24% of the WB and GB groups, respectively (p = .372). P-control charts indicated a weekly mean incidence of 30% during WB practice, which decreased to 24% with GB practice. Among 106 STS-indexed cardiac surgery cases, mean composite outcome incidence decreased from 19% to 6% following our GB transition. Additionally, cooling, and warming rates indexed to patient BSA and VIS at case completion were not significantly different. Our analysis demonstrated a safe transition from WB to GB heater-cooler technologies in our practice. This early analysis suggests that GB heater coolers may be safely adopted to mitigate the risks of nontuberculous mycobacterium infections for cardiac surgical patients.

Homograft Aortic Root Replacement for Destructive Prosthetic Valve Endocarditis: Results in the Current Era.

Background: Destructive aortic prosthetic valve endocarditis portends a high morbidity and mortality, and requires complex high-risk surgery. Homograft root replacement is the most radical and biocompatible operation and, thus, the preferred option. Methods: A retrospective analysis was conducted on 61 consecutive patients who underwent a cardiac reoperation comprising homograft aortic root replacement since 2010. The probabilities of survival were calculated with the Kaplan-Meier method, whereas multivariable regression served to outline the predictors of adverse events. The endpoints were operative/late death, perioperative low cardiac output and renal failure, and reoperations. Results: The operative (cumulative hospital and 30-day) mortality was 13%. The baseline aspartate transaminase (AST) and associated mitral procedures were predictive of operative death (p = 0.048, OR [95% CIs] = 1.03 [1-1.06]) and perioperative low cardiac output, respectively (p = 0.04, OR [95% CIs] = 21.3 [2.7-168.9] for valve replacement). The latter occurred in 12 (20%) patients, despite a normal ejection fraction. Survival estimates (±SE) at 3 months, 6 months, 1 year, and 3 years after surgery were 86.3 ± 4.7%, 82.0 ± 4.9%, 75.2 ± 5.6, and 70.0 ± 6.3%, respectively. Survival was significantly lower in the case of AST ≥ 40 IU/L (p = 0.04) and aortic cross-clamp time ≥ 180 min (p = 0.01), but not when excluding operative survivors. Five patients required early (two out of the five, within 3 months) or late (three out of the five) reoperation. Conclusions: Homograft aortic root replacement for destructive prosthetic valve endocarditis can currently be performed with a near 90% operative survival and reasonable 3-year mortality and reoperation rate. AST might serve to additionally stratify the operative risk.

A propensity-matched analysis of cardiac operation in patients with and without cardiac amyloidosis

ObjectiveThere are limited data on the outcome of routine cardiac operations in patients with cardiac amyloidosis. This study studied the impact of amyloidosis on early and late results of cardiac operations. MethodsThis was a retrospective, propensity-matched, case-control study of patients with cardiac amyloidosis undergoing cardiac surgery. Heart transplantation and ventricular assist implantation were excluded. Controls were patients without known cardiac amyloidosis matched on baseline patient characteristics, echocardiographic findings, and type of operation. Outcomes included operative complications and survival. ResultsIn total, 42 patients with cardiac amyloidosis (amyloid group [AG]) were matched with 168 controls (CON group). The median left ventricular ejection fraction was 63% in the AG group (vs 64% CON). Aortic valve replacement and septal myectomy were the most common operations. Cardiopulmonary bypass (P = .374) and crossclamp (P = .185) times were similar in the 2 groups. Complication rates were similar in the 2 groups, including the need for mechanical circulatory support (n = 1 AG group vs n = 1 CON; P = .361) and intra-aortic balloon pump use (n = 3 AG group vs n = 13 CON; P = 1.000). There were no operative deaths. Survival was similar in the 2 groups at 1 year (AG 93% vs 89% CON; P = .1) but was worse in the AG at 5 years (59% vs 68% CON; P = .1). ConclusionsEarly procedural outcomes and 1-year survival are similar in patients with and without cardiac amyloidosis with preserved cardiac function. Diagnosis of amyloidosis should not be a contraindication to cardiac surgery.

Early and late experience of the modified aortic reimplantation operation

ObjectiveValve-sparing aortic root replacement for proximal aortic dilation with aortic regurgitation is associated with excellent outcomes. Modified aortic reimplantation entails reducing the anulus size to the expected size for sex and body surface area and creating neosinuses to preserve the aortic valve. We present our mid- and late-term outcomes with the modified technique, including a single-surgeon's experience over the past 2 decades. MethodsFrom January 2002 to January 2024, 528 patients underwent modified aortic reimplantation for aortic aneurysm or dilation; 491 were included in this study. End points included time-related mortality and postoperative morbidities, including aortic valve reintervention and longitudinal aortic regurgitation grade. ResultsThere were no operative deaths. Survival at 30 days, 1 year, and 15 years were 100%, 99.6%, and 87%, respectively. Postoperative stroke occurred in 4 patients (0.81%) and reoperation for bleeding in 7 (1.4%). Moderate or severe aortic valve regurgitation was seen in 6.2% and 10% of patients at 1 and 10 years, respectively. Aortic valve mean gradients were 7.0 and 7.5 mm Hg at 1 and 10 years, respectively. Freedom from reintervention on the aortic valve was 99.9%, 99%, and 95% at 30 days, 1 year, and 15 years, respectively. ConclusionsModified aortic reimplantation technique is a reliable and reproducible technique with excellent mid- and long-term outcomes in survival and freedom from reintervention. The results advocate for modified reimplantation in patients with enlarged aortic roots, especially in younger patients with connective tissue disorder.

Reoperative extended arch repair for acute type A aortic dissection after previous cardiac surgery: insights from a relatively young redo series.

To evaluate the impact of previous cardiac surgery (PCS) on clinical outcomes after reoperative extended arch repair for acute type A aortic dissection. This study included 37 acute type A aortic dissection patients with PCS (PCS group) and 992 without PCS (no-PCS group). Propensity score-matching yielded a subgroup of 36 pairs (1:1). In-hospital outcomes and mid-term survival were compared between the 2 groups. The PCS group was older (56.7 ± 14.2 vs 52.2 ± 12.6 years, P = 0.036) and underwent a longer cardiopulmonary bypass (median, 212 vs 183 min, P < 0.001) compared with the no-PCS group. Operative death occurred in 88 (8.6%) patients, exhibiting no significant difference between groups (13.5% vs 8.4%, P = 0.237). Major postoperative morbidity was observed in 431 (41.9%) patients, also showing no difference between groups (45.9% vs 41.7%, P = 0.615). Moreover, the multivariable logistic regression analysis revealed that PCS was not significantly associated with operative mortality (adjusted odds ratio 2.58, 95% confidence interval 0.91-7.29, P = 0.075) or major morbidity (adjusted odds ratio 1.92, 95% confidence interval 0.88-4.18, P = 0.101). The 3-year cumulative survival rates were 71.1% for the PCS group and 83.9% for the no-PCS group (log-rank P = 0.071). Additionally, Cox regression indicated that PCS was not significantly associated with midterm mortality (adjusted hazard ratio 1.40, 95% confidence interval 0.44-4.41, P = 0.566). After matching, no significant differences were found between groups in terms of operative mortality (P > 0.999), major morbidity (P > 0.999) and midterm survival (P = 0.564). No significant differences were found between acute type A aortic dissection patients with PCS and those without PCS regarding in-hospital outcomes and midterm survival after extended arch repair.

Short-term Outcomes of Laparoscopic Versus Open Liver Resection in the Elderly: A Propensity Score-matched Analysis.

With the aging of the population, there is a rising proportion of elderly patients undergoing liver resection. However, the safety and efficacy of laparoscopic liver resection (LLR) in the elderly have not yet been established. In this study, we compared the short-term results of LLR and open liver resection (OLR) in elderly patients using propensity score matched (PSM) analysis. The study comprised 237 elderly patients aged 65 years and older who had undergone liver resection between 2015 to 2021, excluding biliary and vascular reconstruction and simultaneous surgeries other than liver resection. We conducted PSM analysis for baseline characteristics (age, sex, BMI, ASA-PS, disease, procedure, tumor size, and number of tumors) to eliminate potential selection bias. We then compared short-term postoperative outcomes between LLR and OLR groups in patients selected by PSM analysis. Applying PSM analysis, 90 cases each were selected for the LLR and OLR groups. The LLR group had a significantly lower complication rate (Clavien-Dindo: CD ≥II) (19% vs. 33%, p=0.03), especially bile leakage (CD ≥II) (0% vs. 6.7%, p=0.03) compared with those in the OLR group. In addition, a shorter operation time (244 min vs. 351 min, p<0.01), less blood loss (150 ml vs. 335 ml, p<0.01), and shorter hospital stay (8 days vs. 12 days, p<0.01) were observed in the LLR group. No operative or in-hospital deaths were observed in both groups. LLR can be safely performed in elderly patients and offers better short-term outcomes.

Surgical Management of Norwood Procedure for Atypical Aortic Arch.

Background: Postoperative restenosis of the aortic arch after the Norwood procedure is still an important complication that significantly affects surgical outcomes. The rarity of the Norwood procedure for atypical aortic morphology means appropriate arch reconstruction methods and postoperative complications are still unknown. This study aimed to assess the rate of arch reintervention and clinical outcomes after the Norwood procedure for atypical aortic arch. Methods: This retrospective single-center study was conducted between 2001 and 2022. Sixteen patients were identified, eight with a right aortic arch, five with transposition of the great arteries, one with a right aortic arch and transposition of the great arteries, and two with a large tortuous patent ductus arteriosus connected to the opposite side of the descending aorta. We selected and performed four different surgical techniques depending on each aortic arch morphology. Results: Except for one case, autologous tissue-only arch reconstruction was possible. There was one operative death and four late deaths. Overall, no patients required any surgical or catheter-based reintervention for the aortic arch. On the other hand, left pulmonary artery stenosis due to a narrow subaortic space was found in two patients. Conclusions: The Norwood procedure for atypical aortic arch was performed with good results by choosing the appropriate technique for each morphology. On the other hand, pulmonary artery stenosis is likely to occur especially in the transposition of the great arteries group. Therefore, careful surgical method selection or further improvement of the technique that allows retroaortic space should be considered.

First report from the European registry for anomalous aortic origin of coronary artery (EURO-AAOCA).

Anomalous aortic origin of a coronary artery (AAOCA) is a group of rare congenital heart defects with various clinical presentations. The lifetime-risk of an individual living with AAOCA is unknown, and data from multicentre registries are urgently needed to adapt current recommendations and guide optimal patient management. The European AAOCA Registry (EURO-AAOCA) aims to assess differences with regard to AAOCA management between centres. EURO-AAOCA is a prospective, multicentre registry including 13 European centres. Herein, we evaluated differences in clinical presentations and management, treatment decisions and surgical outcomes across centres from January 2019 to June 2023. A total of 262 AAOCA patients were included, with a median age of 33 years (12-53) with a bimodal distribution. One hundred thirty-nine (53.1%) were symptomatic, whereas chest pain (n = 74, 53.2%) was the most common complaint, followed by syncope (n = 21, 15.1%). Seven (5%) patients presented with a myocardial infarction, 2 (1.4%) with aborted sudden cardiac death. Right-AAOCA was most frequent (150, 57.5%), followed by left-AAOCA in 51 (19.5%), and circumflex AAOCA in 20 (7.7%). There were significant differences regarding diagnostics between age groups and across centres. Seventy-four (28.2%) patients underwent surgery with no operative deaths; minor postoperative complications occurred in 10 (3.8%) cases. Currently, no uniform agreement exists among European centres with regard to diagnostic protocols and clinical management for AAOCA variants. Although surgery is a safe procedure in AAOCA, future longitudinal outcome data will hopefully shed light on how to best decide towards optimal selection of patients undergoing revascularization versus conservative treatment.

Mid-term clinical outcomes of totally endoscopic repair for mitral regurgitation in Barlow's disease.

This study aimed to confirm the safety and feasibility of totally endoscopic repair for mitral regurgitation (MR) in Barlow's disease. From June 2018 to December 2022, 21 consecutive Barlow's disease patients (aged 33 ± 12 years; 57.1% male) underwent totally endoscopic mitral valve (MV) repair with leaflets folding, multiple artificial chordae implantation and ring annuloplasty. The safety and feasibility of this technique was evaluated by its mid-term clinical outcomes. There was no operative death or complications. The mean cardiopulmonary bypass (CPB) time was 190 ± 41 (128-267) min, and the aortic cross-clamp time was 145 ± 32 (66-200) min. The average number of artificial chordae implantation was 2.9 ± 0.7 (1-4) pairs. The mean MV coaptation length was 1.4 ± 0.3 (0.8-1.8) cm, and the median transvalvular gradient was 1 [interquartile range (IQR), 1-2] mmHg. During a median follow-up time of 24 (IQR, 10-38) months, all patients showed persistent effective valve function with no significant MR or systolic anterior motion. Totally endoscopic repair was a safe, effective, and reproducible procedure with satisfied mid-term clinical outcomes for MR in Barlow's disease. However, further randomized and long-term follow-up studies were warranted to determine its clinical effects.

Endoscopic transorbital approach in children: surgical technique and early results.

In this study, the authors aimed to describe the endoscopic transorbital approach (ETOA) in children. Six pediatric patients (2 girls and 4 boys) underwent the ETOA for paramedian skull base lesions at a single institution between September 2016 and February 2023. The median age at the time of surgery was 7.5 (range 4-18) years. The median follow-up period was 33 (range 9-60) months. In this series, the ETOA level of difficulty included stage 1 (n = 2, 33.3%), stage 3 (n = 3, 50%), and stage 5 (n = 1, 16.7%). The ETOA was performed for tumor resection in 4 cases; the final pathology consisted of fibrous dysplasia, pilocytic astrocytoma, metastatic neuroblastoma, and choroid plexus papilloma. The procedure was also performed for repair of a petrous apex meningocele and for lateral orbital wall decompression of traumatic lateral rectus muscle entrapment. One patient experienced a transient cranial nerve III palsy after the procedure. There were no operative deaths in this series. In select cases, the ETOA can be considered a minimally invasive alternative for conventional skull base approaches in the armamentarium of pediatric skull base surgery. Further investigation and the accumulation of experience are warranted in the future to enhance the efficacy and applicability of the ETOA in pediatric patients.

Comparison of open thoracoabdominal repair for chronic aortic dissections and aneurysms

ObjectiveAortic dissection is common in patients undergoing open surgical repair of thoracoabdominal aortic aneurysms (TAAAs). Most often, dissection is chronic and is associated with progressive aortic dilatation. Because contemporary outcomes in chronic dissection are not clearly understood, we compared patient characteristics and outcomes after open TAAA repair between patients with chronic dissection and those with non-dissection aneurysm. MethodsWe retrospectively analyzed data from 3470 open TAAA repairs performed in a single practice. Operations were for non-dissection aneurysm in 2351 (67.8%) and chronic dissection in 1119 (32.2%). Outcomes included operative mortality and adverse events, a composite variable comprising operative death and persistent (present at discharge) stroke, paraplegia, paraparesis, and renal failure necessitating dialysis. Logistic regression identified predictors of operative mortality and adverse events. Time-to-event analyses examined survival, death, repair failure, subsequent progressive repair, and survival free of failure or subsequent repair. ResultsCompared with patients with non-dissection aneurysm, those with chronic dissection were younger, had fewer atherosclerotic risk factors, and were more likely to have heritable thoracic aortic disease and undergo extent II repair. The operative mortality rate was 8.5% (n = 296) overall and was higher in non-dissection aneurysm patients (n = 217; 9.2%) than in chronic dissection patients (n = 79; 7.1%; P = .03). Adverse events were less frequent (P = .01) in patients with chronic dissection (n = 145; 13.0%), 22 (2.0%) of whom had persistent paraplegia. Chronic dissection was not predictive of operative mortality (P = .5) or adverse events (P = .6). Operative mortality and adverse events, respectively, were independently predicted by emergency repair (odds ratio [OR], 3.46 and 2.87), chronic kidney disease (OR, 1.74 and 1.81), extent II TAAA repair (OR, 1.44 and 1.73), increasing age (OR, 1.04/year and 1.04/year), and increasing aortic cross-clamp time (OR, 1.02/minutes and 1.02/minutes). Patients with chronic dissection had lower 10-year unadjusted mortality (42% vs 69%) but more frequent repair failure (5% vs 3%) and subsequent repair for progressive aortic disease (11% vs 5%) than patients with non-dissection aneurysm (P < .001); these differences were no longer statistically significant after adjustment. ConclusionsOutcomes of open TAAA repair vary by aortic disease type. Emergency repairs and atherosclerotic diseases most commonly occur in patients with non-dissection aneurysm and independently predict operative mortality. Repair of chronic dissection is associated with low rates of adverse events, including operative mortality and persistent paraplegia, along with reasonable late survival and good durability. However, patients with chronic dissection tend to more commonly undergo subsequent repair to treat progressive aortic disease, which emphasizes the need for robust long-term imaging surveillance protocols.

Robot-assisted thoracic surgery for benign tumors at the cervicothoracic junction: a propensity-matched study

This study aimed to assess the feasibility and safety of robot-assisted thoracic surgery (RATS) for resecting benign tumors of the cervicothoracic junction. Between 2017 and 2021, a total of 54 patients with benign cervicothoracic junction tumors were included. Among them, 46 underwent RATS while 8 underwent open surgery. Using a propensity score based on four variables (age, sex, comorbidity, and tumor size). The outcomes compared included short-term outcomes such as blood loss, as well as long-term outcomes including respiratory function and patients' postoperative health-related quality of life. No operative deaths occurred in this study. RATS was associated with less intraoperative blood loss (102 < 380 ml, P = 0.001) and a shorter length of hospital stay (1.8 < 4.8, P < 0.001). After a median follow-up of 37 months, no recurrences were reported, and no statistically significant differences were found in the 3-year survival between the two groups. The postoperative respiratory function of patients with open surgery showed a significant decrease compared to preoperative levels and were lower than those of RATS patients. In terms of health-related quality of life, RATS was associated with a better mean EQ-5D-5L index than open surgery (0.808 > 0.650, P < 0.05). In RATS, tumor sizes > 5 cm (mean ± SD = 0.768 ± 0.111, P = 0.028) and neurogenic tumors (mean ± SD = 0.702 ± 0.082, P < 0.001) remained significantly and independently associated with a lower EQ-5D-5L index. This study demonstrated that robot-assisted thoracic surgery for benign tumors of the cervicothoracic junction is a safe and technically feasible procedure, particularly for tumors < 5 cm and non-neurogenic tumors.

Pedicled pericardial patch in tracheal reconstruction in children – Novel technique to provide vascularized tissue for salvaging difficult airways

BackgroundManagement of large central airway defects are often complex. Children who present with these defects have multiple co-morbidities or have had previous surgeries. Surgical options include various tissue cover for these defects without longer term benefits. Vascularized autologous pericardial patch offers a better solution to these defects by providing vascularity and potential for remodelling in future. Methods41 children (M:F of 24:17) were operated for large trachea-bronchial defects between January 2015 and August 2022. The median age of was 12 months with median weight of 8.9 kg (IQR 3.3 kg–17.7 kg) Causes leading to the central tracheal defect include failed repair of previous trachea-oesophageal fistula (TOF) (n = 21) and acquired fistula due to button battery injury (n = 11). Surgical repair consisted of autologous pedicled pericardial patch repair for the airway defect under cardiopulmonary bypass. ResultsThere were two operative deaths related to extensive sepsis and necrosis of reconstructed trachea. Four children had further reoperation with additional patch. Bronchoscopy was used as surveillance in all these children, with use of airway stents (biodegradable stent) in 9 children. The median ventilation time was 8 days, with tracheostomy being needed in 5 for long term support. ConclusionsAutologous pericardial patch is a versatile technique and can be used to salvage large tracheal defects when other method have failed or not feasible. Tracheomalacia at the site of repair could be managed with biodegradable stents. Vascularity and ciliary function of the patch still needs to be evaluated.

Long-term outcomes of stapled closure of the aortic stump with axillo-bifemoral bypass grafting for abdominal aortic infection

ObjectivesThe stapled suture is used to close the aortic stump during surgery for abdominal aortic infection. The current study aimed to investigate the short- and long-term outcomes of stapled closure of the aortic stump with axillo-bifemoral (AxBF) bypass grafting. MethodsThe short- and long-term outcomes of 11 patients who underwent surgery for abdominal aortic infection were retrospectively analyzed. ResultsOf 11 patients, 7 underwent stapled closure of the aortic stump with AxBF bypass grafting, and four underwent other reconstructive procedures with no aortic stump. Four patients (three who underwent stapled closure of the aortic stump and one who underwent other reconstructive procedures without the aortic stump) had operative death. However, none of the patients had aortic stump blow-out during the same hospitalization for surgery. The 1- and 5-year survival rates of the patients who underwent stapled closure of the aortic stump with AxBF bypass grafting were 57% and 29%, respectively. One patient developed aorto-duodenal fistula at 32 months after surgery. The patient survived for 12 months until bleeding in the recurrent aorto-enteric fistula occurred. ConclusionStapled closure of the aortic stump is durable. The use of a linear stapler is a useful technique for reinforcing the aortic stump in patients who underwent excision of an infected abdominal aortic aneurysm or an infected abdominal graft.

Results of the inoperable and operable with aortic valve endocarditis.

To evaluate the results of the inoperable and operable with aortic valve endocarditis, focus on risk factors, significance, and management of destruction of the aortic annulus in aortic valve endocarditis. The retrospective study was completed to investigate patients with aortic valve endocarditis undergoing cardiac surgery between January 2006 and November 2022 at our hospital. 512 patients were divided into group with destruction of the aortic annulus (n = 80) and without destruction of the aortic annulus (n = 432). There were 32 operative deaths (6.3%, 32/512). By univariate and multivariate analysis, destruction of the aortic annulus is found to be statistically significantly associated with in-hospital mortality (P < 0.001), prolonged mechanical ventilation time (mechanical ventilation time > 96 h, P = 0.018), early aortic paravalvular leak (P < 0.001), and 1-year mortality following cardiac surgery (P < 0.001), respectively. In our study, destruction of the aortic annulus increases mortality and health care costs. Optimization of pre-, peri-, and postoperative factors can reduce mortality and morbidity in aortic valve endocarditis. Aortic root replacement could be recommended as the best practice choice for aortic valve endocarditis with periannular abscess and destruction of the aortic annulus.

A modified Blumgart method using a homemade crochet needle facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy: a retrospective cohort study

BackgroundAmong the safest procedures for anastomosis in pancreaticoduodenectomy, Blumgart pancreaticojejunostomy is associated with low rates of postoperative pancreatic fistula (POPF) and postoperative complications. However, this technique is difficult to perform during laparoscopic pancreaticoduodenectomy (LPD). This study presents a modified Blumgart method using a homemade crochet needle to facilitate laparoscopic pancreaticojejunostomy and evaluates its safety and reliability.MethodsFrom February 2019 to October 2022, 96 LPD surgeries with the new technique were performed by the same surgeons in the Second Affiliated Hospital of Zhejiang University School of Medicine. The operative details (operative time, pancreaticojejunostomy time, POPF rate, postoperative complication rate, mortality rate) were analyzed along with clinical and pathological indicators (pancreatic duct diameter, pancreatic texture, and histopathological findings).ResultsThere were 54 men and 42 women with a mean age of 63.38 ± 10.41 years. The intraoperative bleeding volume, operative time and postoperative length of hospital stay were 198.43 ± 132.97 mL, 445.30 ± 87.05 min and 13.68 ± 4.02 days, respectively. The operation time of pancreaticojejunostomy was 66.28 ± 10.17 min. Clinically relevant POPFs (grades B and C) occurred in 14.6% of patients. Only one patient had postoperative abdominal hemorrhage and was cured after reoperation. There were no operative or in-hospital deaths. With our proposed modification, the pancreatic duct and jejunal orifice are aligned correctly during duct-to-mucosa (DTM) after the application of external traction through the homemade crochet needle. The space between the posterior wall of pancreatic remnant and jejunal loop can be exposed by adjusting the tension of the external threads, which can facilitate DTM.ConclusionsA modified Blumgart method using a homemade crochet needle could be technically feasible and safe during LPD. A randomized control trial is needed to confirm these findings.

The Remadi’s technique or the Bentall Technic? Valsalvas Reduction Plasty

The objective of this study was to find an another surgical way than Bentall procedure to treat the aneurysms of ascending aorta involving the sinuses of valsalvas. From September 2008 to May 2018, eighty five patients underwent aortic valve replacement (AVR) associated with a Valsalva plasty, with or without the replacement of the ascending aorta. All the procedures were performed by a single surgeon (Remadi’s technique) at Amiens Universitary Hospital in France. There was no operative death. During the follow-up at ten years, the diameters of the Sinuses of Valsalva remain steady, without long term post-operative aneurysm or reoperation for any aortic complication. This original new technic, can be applied safety for almost all ascending aorta aneurysms involving valsalvas (more than 90% of cases) instead of the bentall procedure. This new technic is safe with excellent immediate and mid- term results. The Remadi’s technic is particularly adapted for the older patients or patients with associated comorbidity in order to reduce the operative risk. The Bentall’technic should be performed only when the ascending aorta has a shape like a « chianti bottle with very important dilatation of sinuses of valsalvas, when its the only procedure adapted for those remaining indications.