Patch Interposition Research Articles

Synthetic polytetrafluoroethylene patches for irreparable rotator cuff tears-how are they doing at 5 years?

Treating massive and irreparable rotator cuff tears are problematic. Several studies have reported that polytetrafluoroethylene (PTFE) patches demonstrated excellent construct integrity and positive clinical and patient outcomes. However, these studies either had small sample sizes or short follow-up periods. To determine the survivorship, efficacy, and medium-term (2-19 years) outcomes of PTFE patch repairs. This retrospective study used prospectively collected data to establish the medium-term outcomes of PTFE interposition patch repairs for massive rotator cuff tears that could not be repaired by the standard technique. Patients included those who met the ≥2-year follow-up criteria post repair. Standardized assessments of patient-ranked shoulder pain and function and shoulder strength and passive range of motion (ROM) were performed preoperatively and at follow-up visits. Radiographs and ultrasonography were used to evaluate repair integrity, measure proximal humeral head migration, and determine glenohumeral arthritis scores. Forty-one shoulders formed the study cohort at a mean follow-up period of 5 years (range: 2-19 years). The mean age of this group was 72 (standard deviation: 10; range: 50-88) and had 14 cm2 tears at surgery. Twenty-five of 41 (61%) PTFE interposition patch repairs remained intact at an average of 5 years postrepair. Thirteen patches failed at the patch-tendon junction, 1 was removed, and 2 patients underwent reverse total shoulder replacement. Patient-ranked shoulder stiffness (P<.05), frequency of pain during activity and sleep (P<.001), pain levels during overhead activity and rest (P<.001), and overall shoulder function significantly improved from bad preoperatively to fair at the mean 5-year postoperative visit (P<.001). No significant improvements were demonstrated in dynamometer-measured shoulder strength maneuvers and passive ROM. All patients demonstrated proximal humeral head migration on shoulder radiographs regardless of repair integrity (mean Upper Migration Index=1.2). Failed repairs were associated with higher mean preoperative glenohumeral arthritis grades compared with intact repairs (grade 2 in failed repairs compared with grade 1 in intact repairs) (P<.01). PTFE interposition patch repairs for massive and irreparable tears had good construct integrity and clinical outcomes at 2 years. These outcomes were not maintained. PTFE patch repairs often failed at the patch-tendon junction at 4 years and beyond and were ineffective in (1) preventing proximal humeral head migration, (2) stopping progression of glenohumeral arthritis, and (3) improving shoulder strength and ROM.

Reparación valvular en la endocarditis mitral

IntroductionInfective endocarditis (IE) is a pathology with a high morbidity and mortality rate and represents a growing public health problem. Surgical treatment is necessary in more than half of the cases, and its main purpose is to completely remove the infected tissue and reconstruct normal cardiac anatomy, including repair or replacement of the affected valve(s). Objectives and methodsThe present study focuses on describing the most appropriate procedure for mitral repair surgery in cases of IE, based on the literature and the extensive experience gained by the surgical team. Likewise, we have compiled through a systematic search of the literature the results that have been reported on reparative surgery compared to mitral valve replacement. ResultsThe surgical technique described requires a thorough study of the degree of involvement and destructuring of the different valve segments. We consider resection with pericardial patch interposition and/or Goretex® neochord implantation to be the standard technique that allows reproducible results. The structured review of the available scientific evidence verifies the safety of mitral repair for the treatment of IE, providing significant benefits compared to valve replacement. ConclusionThe evaluated surgical results suggest that mitral repair surgery should be considered the procedure of choice for the surgical treatment of IE, whenever technically feasible.

The effect of fibrin formulation on cell migration in an in vitro tendon repair model

BackgroundThe purpose of this study was to determine the effect of fibrinogen concentration on cell viability and migration in a tissue culture tendon healing model. MethodsForty-eight canine flexor digitorum profundus tendons were randomly divided into three groups. In each group the tendons were lacerated and repaired augmented with a canine bone marrow stromal cell seeded fibrin interposition patch using either 5 mg/ml fibrinogen and 25 U/ml thrombin (physiological as a control), 40 mg/ml fibrinogen and 250 U/ml thrombin (low adhesive), or 80 mg/ml fibrinogen and 250 U/ml thrombin (high adhesive). The sutured tendons were cultured for two or four weeks. ResultsFailure load was not significantly different among the groups. Cell-labeling staining showed that the stromal cells migrated across the gap in the control and low adhesive groups, but there was no cell migration in the high adhesive group at two weeks. Conclusion: A high fibrinogen concentration in a fibrin patch or glue may impede early cell migration. Level of evidenceNot applicable because this study was a laboratory study.

Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature

Introduction and hypothesisThe use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery.MethodsA prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up).ResultsNinety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%).ConclusionsThe long-term rate of mesh erosion following an abdominally placed synthetic graft is low.

Can vein patch interposition after sapheno-femoral ligation prevent postoperative neovascularization at the saphenofemoral junction?

Background: Majority of recurrence of varicose veins following both primary and repeated surgery was attributable to neovascularization. The aim of this study was to evaluate the efficacy and safety of the new natural origin anatomical barrier (vein patch) in decreasing neovascularization after initial surgery.Methods: The study included 50 patients with primary varicose vein and incompetence of SFJ. The patients are divided randomly into 2 groups, group (A) (conventional surgical group) and group (B) (barrier technique group), each one included 25 patients. In group (A) SFJ ligation with ligation of all the tributaries and stripping of great saphenous vein (GSV) in the thigh portion was done. In group (B), after conventional surgical procedure was done vein patch was taken from striped LSV. The vein patch was applied on the cribriform fascia opening. This barrier of vein patch is reinforced by good tight subcutaneous tissue suture.Results: Neovascularization was seen on duplex in 4 (16%) limbs of group (A) conventional surgical group at one year follow up, but in group (B) barrier technique group neovascularization was seen only in one (4%) limb. Groin infection was registered in 3 (12%) limbs, 2 (8%) of them in group (A) conventional surgical group and the third one (4%) in the group (B) barrier technique group.Conclusions: Vein patch interposition after correctly SFJ ligation seems to lower the incidence of neovascularisation after one year. This technique may constitute additional option to prevent recurrence.

A Comparison of Two Arthroscopic Techniques for Interpositional Polytetrafluoroethylene Patch Repair for Massive Irreparable Rotator Cuff Tears: Speed and Biomechanics.

Interpositional synthetic patch repairs are a novel method of treating massive irreparable rotator cuff tears. However, surgeons experience difficulty in the arthroscopic insertion of these patches. We compared two methods of arthroscopic interpositional synthetic patch repair: the newly devised slide-and-grip technique, using pre-loaded sliding knots and no arthroscopic knots, and the weave technique, using less arthroscopic knot tying than the earlier mattress technique. Study questions were as follows: (1) Would the slide-and-grip technique take less time than the weave technique? (2) Would the biomechanical strength of the two methods be comparable? Fourteen paired ovine infraspinatus tendon ex vivo models of the degenerative human rotator cuff underwent timed repair with a synthetic polytetrafluoroethylene (PTFE) patch, using either the weave technique (n = 7) or the slide-and-grip technique (n = 7). Each was pulled to failure using a tensile testing machine, the Instron 8874. The time to complete the slide-and-grip repairs was shorter (12 ± 0.9min) than that of the weave repairs (23 ± 1min). Ultimate load to failure was comparable for the slide-and-grip and weave techniques (211 ± 27N vs. 295 ± 35N, respectively), and the slide-and-grip was less stiff (14 ± 1N/mm vs. 19 ± 1N/mm). The slide-and-grip technique took less time than the weave technique for the interpositional patch repair of massive irreparable rotator cuff tears and when correctly performed had comparable biomechanical strength.

Patch Augmentation and Patch Extension for Complex Rotator Cuff Tears

The successful management of large to massive rotator cuff tears is challenging. Multiple factors to include poor tendon quality with fatty degeneration lead to high retear rates despite improved arthroscopic and open repair techniques. Patch augmentation and patch interposition with various grafts have been studied in an effort to both reinforce and bridge massive rotator cuff repairs, and provide an optimal biologic and mechanical environment at the tendon-bone interface. The purpose of this review is to present the current indications, surgical techniques, and outcomes of patch augmentation and patch interposition (extension) for large and massive rotator cuff tears.

Combined Laparoscopic, Vesicoscopic, and Vaginal Repair of a Vesicovaginal Fistula

Study ObjectiveTo demonstrate a combined laparoscopic, vesicoscopic, and vaginal approach to repair of a complex vesicovaginal fistula. DesignTechnical video demonstrating a combined laparoscopic, vesicoscopic, and vaginal approach for repairing a vesicovaginal fistula (Canadian Task Force classification level III). SettingUrogynecology and Urology Departments of a tertiary referral center for urogynecology. InterventionsA 38-year-old woman presented with a vesicovaginal fistula secondary to a previous total abdominal hysterectomy. An initial attempt to repair the fistula vaginally was unsuccessful owing to infection and comorbidities. After counseling, the patient agreed to a combined laparoscopic, vesicoscopic, and vaginal repair of her vesicovaginal fistula. ConclusionThe incidence of vesicovaginal fistula following a total abdominal hysterectomy for benign causes is 1 in 540 [1]. Management of this complication can be challenging, and success rates vary. Initially, laparoscopy was performed, which allowed mobilization of the omentum to provide an interposition patch between the bladder and vagina after repair of the fistula. The fistula tract was then identified vesicoscopically and excised. Once the tract was closed and the patch secured, a vaginal approach was adopted to excise the remaining fistula tract as well as scar tissue. Interrupted closure of the vagina was performed in multiple layers to reduce the risk of recurrence. We have used vesicoscopy since 2007 for a variety of female urogynecologic problems, including bladder diverticula, ureteric stenosis, vesicoureteric reflux, foreign body removal, and vesicovaginal fistula repair [2]. This combined multidisciplinary approach offers a minimally invasive option for the repair of complex vesicovaginal fistulae, and should be considered in selected complex cases.

Aortic Arch Reconstruction Using “Autologous Pulmonary Artery Patch” as an Interposition Patch Plasty in Interrupted Aortic Arch and Ventricular Septal Defect

Objective: This retrospective analysis aims to evaluate our experience using autologous pulmonary artery interposition patch plasty as an alternative approach in patients with interrupted aortic arch (IAA) if direct anastomosis technique is not possible.

Biomechanical comparison of expanded polytetrafluoroethylene (ePTFE) and PTFE interpositional patches and direct tendon-to-bone repair for massive rotator cuff tears in an ovine model.

Massive irreparable rotator cuff tears are a difficult problem. Modalities such as irrigation and debridement, partial repair, tendon transfer and grafts have been utilized with high failure rates and mixed results. Synthetic interpositional patch repairs are a novel and increasingly used approach. The present study aimed to examine the biomechanical properties of common synthetic materials for interpositional repairs in contrast to native tendon. Six ovine tendons, six polytetrafluoroethylene (PTFE) felt sections and six expanded PTFE (ePTFE) patch sections were pulled-to-failure to analyze their biomechanical and material properties. Six direct tendon-to-bone surgical method repairs, six interpositional PTFE felt patch repairs and six interpositional ePTFE patch repairs were also constructed in ovine shoulders and pulled-to-failure to examine the biomechanical properties of each repair construct. Ovine tendon had higher load-to-failure (591 N) and had greater stiffness (108 N/mm) than either PTFE felt (296 N, 28 N/mm) or ePTFE patch sections (323 N, 34 N/mm). Both PTFE felt and ePTFE repair techniques required greater load-to-failure (225 N and 177 N, respectively) than direct tendon-to-bone surgical repairs (147 N) in ovine models. Synthetic materials lacked several biomechanical properties, including strength and stiffness, compared to ovine tendon. Interpositional surgical repair models with these materials were significantly stronger than direct tendon-to-bone model repairs.

A short-term prospective clinical study of synthetic (ePTFE) interpositional patch repair for irreparable rotator cuff defects

A short-term prospective clinical study of synthetic (ePTFE) interpositional patch repair for irreparable rotator cuff defects

Role of PTFE Patch Saphenoplasty in Reducing Neovascularization and Recurrence in Varicose Veins.

Varicose veins have a high recurrence rate following surgery. Besides poor surgical technique, majority of these recurrences are attributable to neovascularization after both primary and repeat surgery. Authors have studied the effectiveness of a polytetrafluoroethylene (PTFE) patch interposition between the ligated vein stump and the overlying soft tissue at saphenofemoral junction in decreasing recurrence of varicose veins after initial surgery. Study was conducted on 50 patients of varicose veins with saphenofemoral junction incompetence. Patients were randomly divided into two groups, group A and group B alternately. In group A, standard surgical procedure was done followed by PTFE patch application. In group B, same surgical procedure was applied as in group A, with the exception of PTFE patch application. Patients in both groups were given similar postoperative care. A full venous duplex ultrasound assessment was performed in all the patients postoperatively. Neovascularization was observed in five patients (20%) of group B, while it was not seen in any of the patients in group A at 1-year follow-up. This difference in neovascularization across the two groups was found to be statistically significant with a p value of 0.0251. Hence, authors concluded that patch saphenoplasty helps in reducing recurrence in varicose veins by decreasing neovascularization at saphenofemoral junction.

A Comparative Study of the Effects of Growth and Differentiation Factor 5 on Muscle-Derived Stem Cells and Bone Marrow Stromal Cells in an In Vitro Tendon Healing Model

To investigate the ability of muscle-derived stem cells (MDSCs) supplemented with growth and differentiation factor-5 (GDF-5) to improve tendon healing compared with bone marrow stromal cells (BMSCs) in an in vitro tendon culture model. Eighty canine flexor digitorum profundus tendons were assigned into 5 groups: repaired tendon (1) without gel patch interposition (no cell group), (2) with BMSC-seeded gel patch interposition (BMSC group), (3) with MDSC-seeded gel patch interposition (MDSC group), (4) with GDF-5-treated BMSC-seeded gel patch interposition (BMSC+GDF-5 group), and (5) with GDF-5-treated MDSC-seeded gel patch interposition (MDSC+GDF-5 group). After culturing for 2 or 4 weeks, the failure strength of the healing tendons was measured. The tendons were also evaluated histologically. The failure strength of the repaired tendon in the MDSC+GDF-5 group was significantly higher than that of the non-cell and BMSC groups. The stiffness of the repaired tendons in the MDSC+GDF-5 group was significantly higher than that of the non-cell group. Histologically, the implanted cells became incorporated into the original tendon in all 4 cell-seeded groups. Interposition of a multilayered GDF-5 and MDSC-seeded collagen gel patch at the repair site enhanced tendon healing compared with a similar patch using BMSC. However, this increase in vitro was relatively small. In the clinical setting, differences between MDSC and BMSC may not be substantially different, and it remains to be shown that such methods might enhance the results of an uncomplicated tendon repair clinically. Muscle-derived stem cell implantation and administration of GDF-5 may improve the outcome of tendon repair.

Morphologic Changes of Synthetic (ePTFE) Interpositional Patch Repair for Massive Irreparable Rotator Cuff Tear

Background: Massive, irreparable rotator cuff tears are difficult to manage. One option is to replace the lost tissue with a synthetic patch, for example, expanded polytetrafluoroethylene (ePTFE). There is, however, no information regarding ePTFE patch healing in humans. The aim of this study, therefore, was to evaluate healing of an irreparable rotator cuff tear treated with an interpositional ePTFE patch. Methods: The shoulders of consecutive patients undergoing interpositional ePTFE (Gore-Tex) patch repair for reconstruction of an irreparable rotator cuff tear by a single surgeon were evaluated by an experienced ultrasonographer using a standardized protocol, and by validated patient and examiner outcome measures preoperatively, and at 1, 6, 12 weeks, and 6 months postarthroscopic rotator cuff reconstruction. Results: Ten patients with an average age of 64 years (range, 42 to 85 y) and mean±SEM rotator cuff defects of 20±3.3 cm2 repaired with an ePTFE interpositional graft completed the study. Signs of healing on ultrasound were present at the patch to bone interface in 60% (6/10) of shoulders in a week, whereas 30% (3/10) showed signs of healing at the patch to tendon interface at 12 weeks after surgery. ePTFE patch to tendon thickness was 3.1±0.3 mm a week after surgery, decreasing to 1.9±0.2 mm at 6 months (P=0.05). The patch landing site dimensions (7.3±0.9 mm), thickness at the patch to bone interface (3.7±0.3 mm), and vascularity at the patch to bone and patch to tendon interfaces were unchanged over 6 months. The subacromial bursa was thickened at 1 week postoperatively (2.1±0.2 mm), thinned at 6 weeks (1.7±0.2 mm, P=0.04), thicker at 12 weeks (2.2±0.6 mm), and was within normal thickness after 6 months at 1.2±0.1 mm (P<0.0003). Healing at the patch to bone interface was noted in 10/10 patients, and 9/10 patients at the patch to tendon interface, 6 months after surgery. There were no retears. Frequency and level of pain improved (P<0.05), whereas the shoulders were less stiff (P=0.002). The overall rating of patients on their shoulders improved from very bad to poor before surgery to fair to good 6 months after surgery (P=0.002). Internal rotation, external rotation, and adduction strengths improved 1.6-fold (P<0.05), whereas the supraspinatus strength doubled (P=0.0006). Impingement signs were less at 6 months (P=0.001). Conclusions: This study showed excellent healing of massive, irreparable rotator cuff tears after reconstruction using ePTFE interpositional patch. Signs of healing on ultrasound were present at the patch to bone and patch to tendon interfaces at 1 and 12 weeks, respectively. Patch to tendon interface thickness increased after surgery and gradually decreased in thickness after 6 months, whereas the thickening of the subacromial bursa at 1 week after surgery normalized over 6 months. There were no retears. These morphologic changes were accompanied by improvements in pain, strength, and impingement signs.

Application of Small Intestinal Submucosa Graft for Repair of Complicated Vesicovaginal Fistula: A Pilot Study

Vesicovaginal fistula is a socially debilitating problem with important psychological and medicolegal implications. Complicated fistulas include large fistulas or those with failed prior repair attempts. The key to successful closure of such fistulas is the use of adjuncts such as a Martius, peritoneal or omental flap. Small intestinal submucosa is an acellular collagen matrix graft that is nonimmunogenic, biodegradable and ready to use off the shelf. We evaluated small intestinal submucosa as an interposition patch during complicated vesicovaginal fistula repair. A total of 23 women with a mean age of 33.5 years who had a complicated vesicovaginal fistula were enrolled in this clinical trial. Complicating factors were failed primary repair in 9 cases, excessive perifistulous scarring in 4 patients and a fistula 1.5 cm or greater in the remainder. Transvaginal repair was done in 7 low fistula cases and transabdominal repair was done in the remainder with a high fistula. A small intestinal submucosa patch was interposed in all cases at classic abdominal or vaginal repair. All patients were evaluated 1, 3 and 6 months postoperatively. All patients who underwent vaginal repair were dry during followup. Of the 16 women who underwent transabdominal repair 14 were dry. The overall success rate was 91.3%. No reported allergic or inflammatory reactions were documented. Using small intestinal submucosa as an interposition layer at anatomical vaginal and/or transabdominal repair of complicated vesicovaginal fistulas seems to be a simple, feasible solution.

Management of recto-vaginal fistulas after prosthetic reinforcement treatment for pelvic organ prolapse

To communicate our findings on successful treatment of recto-vaginal fistulas (RVFs) after prosthetic reinforcement surgery of pelvic organ prolapse (POP). A retrospective single center study between 1998 and 2008 was performed. A total of 80 patients with RVF were identified, of which five patients (6%), with a mean age of 65 years (range: 52-73), had undergone previous surgery for POP with prosthetic reinforcement. All patients complained about ongoing vaginal infections and febrile episodes. These symptoms were reported after a mean period of 18 mo after POP repair. As a first intervention, three patients underwent ablation of the prosthetic material (PM). As a second intervention, open proctectomy with a primary anastomosis, an omental patch, and a protective ileostomy were performed in two patients. One patient required a terminal colostomy due to complete destruction of the anal sphincters. In two other patients, ablation of the PM and proctectomy was performed as a one-step procedure. The postoperative course in all patients was uneventful, with a mean length of hospitalization of 20 d (range: 15-30). Closure of the ileostomy was achieved in all four patients within four months. After a mean period of 35 mo (range: 4-60) of follow-up, no recurrence was observed with normal continence in four patients. In our experience, the definitive treatment of high RVFs after PM repair for POP necessitates ablation of the PM, proctectomy with a primary colo-rectal anastomosis, an omental patch interposition, and a temporary ileostomy.

Leiomyosarkome

Vascular leiomyosarcoma (LMS) is a rare soft tissue tumor that originates in the smooth muscle cells of the vascular media. It occurs most frequently in the 5 th and 6 th decades of life. Vascular LMS occurs five times more frequently in the large veins than in arteries, and in 60% in the vicinity of the inferior vena cava (VCI); women are afflicted in 80% of cases. These tumors grow expansively, displacing and compressing other organs and causing uncharacteristic symptoms. Diagnosis can be made with computer tomography or magnetic resonance tomography. Opinions vary on preoperative polychemotherapy (PCT). Radical surgical resection is at present the only treatment that has a favorable influence on long-term survival. Surgical options include tangential resection of the tumor and the involved segment of the vena cava with or without patch plastic, tumor resection and interposition of a Goretex® prosthesis, or resection and ligation of the VCI when a thrombosis has been diagnosed preoperatively. Postoperative chemotherapy is said to reduce local recurrences. These rare and highly malignant tumors have a poor prognosis, with a 5-year survival rate for curatively operated patients of 28%. Diagnosis, treatment and prognosis are discussed on the basis of three cases.

Fate of the Truncal Valve in Truncus Arteriosus

The fate of the truncal valve (TV) after truncus arteriosus repair remains poorly defined. The purpose of this report was to analyze how the TV influences outcome of truncus arteriosus repair. From January 1986 to December 2003, 153 patients underwent complete repair of the truncus arteriosus. Median age was 35 days. Preoperative TV insufficiency was absent or trivial in 59 patients (39%), mild in 72 patients (47%), moderate in 13 patients (8%), and severe in 9 patients (6%). The TV was quadricuspid in 36 patients (24 %), bicuspid in 10 patients (7%), and tricuspid in the remaining patients. At surgery, TV plasty (n = 6) or replacement (n = 3) was associated with truncus arteriosus repair. Truncal valve-aorta continuity was restored by patch interposition in 27 patients (17%), by conduit in 7 patients (5%), and directly in the remaining patients. A 97-month mean follow-up was achieved in all survivors. The actuarial survival rates were 81.7% +/- 3.1% and 79.1% +/- 3.3% at 6 months and 18 years, respectively. Among 85 patients who underwent 113 reoperations, 19 underwent 24 TV reoperations: 5 isolated TV reinterventions and 19 associated with right ventricular-pulmonary artery conduit replacement. Freedom from TV reoperation was 96%, 82.3%, and 62.7% at 1, 10, and 18 years, respectively. Multivariate logistic regression showed that moderate or severe TV insufficiency at initial presentation was a risk factor for late TV reoperation but not for early mortality. Initial TV replacement was associated with lower survival. Initial TV insufficiency is associated with higher reoperation rate. This condition requires more refined techniques of TV plasty. The overall long-term freedom of TV reintervention rate remains within reasonable ranges. Truncal valve reintervention presents a low risk for mortality.

Invited commentary

The management of truncus arteriosus has evolved, and results are now more consistent [1Henaine R. Azarnoush K. Belli E. et al.Fate of the truncal valve in truncus arteriosus.Ann Thorac Surg. 2008; 85: 172-178Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar]. As has been well described, however, the primary approach to truncus arteriosus and to significant associated lesions, such as interrupted aortic arch and truncal valve insufficiency, remain the major risk factors for reoperation and mid to late survival rates. The initial management of truncal valve is a good example of the problems that arise when pediatric cardiac surgeons try to standardize therapy. The lack of consensus on timing and surgical techniques for treatment of moderate or severe truncal valve insufficiency impacts mid- and long-term outcomes. Nowadays, rational analysis of specific lesions and possible solutions is recommended. The following are influential lesions that may impact results:1Truncal valve morphology that includes dysplastic, dysfunctional, and an abnormal number of leaflets; conal septal hypoplasia; and valve prolapse due to the ventricle septal defect (VSD) should be considered.2Aortic arch obstruction and anomalous coronary anatomy are important associated lesions.3Morphology of the pulmonary arteries and their relationship to the aorta should be inspected. The following are some influential solutions that have contributed to improved results:1Use of direct anastomosis, patch interposition, or conduit to produce truncal valve/aorta continuity.2Improve truncal valve function by truncal valve replacement, commissuroplasty, external or internal annuloplasty, truncal valve reduction, creating a functional tricuspid semilunar valve, or attachment of edges of prolapsed leaflets.3VSD closure using appropriate right ventriculotomy and patch size. I have found the following procedures and guidelines to be helpful:1For moderate to severe truncal valve insufficiency, truncal valve repair is the most desirable and first choice.2Multiple leaflets (more than three) require careful attention.3Carefully consider the efficacy of different valvuloplasty alternatives.4Avoid valve replacement as a first option.5Prevent injury to truncal valve commissures during dissection of pulmonary arteries.6Try to construct an ascending aorta of uniform diameter, usually by using a direct anastomosis to reestablish truncal valve–aortic continuity.7Limit the incision distance of your right ventriculotomy through the truncal valve orifice.8Close the VSD with a large patch that is a larger size than the truncal valve orifice.9Assess the function of the truncal valve using an infusion of cardioplegia through the ascending aorta; view the valve from the right ventricle before finishing the VSD closure.10Take advantage of a perioperative transesophageal echocardiographic evaluation, and remember that truncus arteriosus is a challenging disease so repair. Fate of the Truncal Valve in Truncus ArteriosusThe Annals of Thoracic SurgeryVol. 85Issue 1PreviewThe fate of the truncal valve (TV) after truncus arteriosus repair remains poorly defined. The purpose of this report was to analyze how the TV influences outcome of truncus arteriosus repair. Full-Text PDF

Corporoplasty for Advanced Peyronie’s Disease Using Venous And/or Dermis Patch Grafting: New Surgical Technique And Long-term Patient Satisfaction

We evaluated long-term results and patient satisfaction after corporoplasty using saphenous vein and/or dermis patch grafting in patients with advanced Peyronie's disease. A total of 20 patients who underwent venous and/or dermis patch corporoplasty were followed a mean of 19 months. Postoperatively patients satisfaction was assessed using the International Index of Erectile Function questionnaire. The mean preoperative grade of deviation in this collective was 86 degrees, frequently associated with additional malrotation. Intraoperatively the deviation was straightened in all cases. Postoperatively 20% of patients complained of 1 or 2 cm. penile shortening and in 25% there was a slight deviation relapse of 5 to 15 degrees. Only 2 patients had recurrence (30 and 70 degrees, respectively. In 3 cases (15%) postoperative erectile dysfunction was treated successfully with sildenafil or prostaglandin E. Overall postoperative sexual satisfaction score on the International Index of Erectile Function was 2.76 of a possible 5, although erection and cohabitation status were rated higher with at 3 and 2.94, respectively. Saphenous vein interposition is safe and effective for high grade Peyronie's disease. In cases of insufficient vein anatomy additional dermis patch interposition is a good alternative. The limited median postoperative patient satisfaction score even for minor procedures with good objective results indicates only moderate overall satisfaction at a mean of 19 months postoperatively, which was likely due to high preoperative patient expectation of surgical correction.