Cotite Apendicular - Relato de Caso / Stump appendicitis - Case Report

Cotite apendicular é uma rara complicação pós-apendicectomia, que se caracteriza por ser uma inflamação do coto apendicular remanescente devido à obstrução do seu lúmen, geralmente por um fecalito. Isso aumenta a pressão intraluminal, prejudica a drenagem venosa e facilita subsequente infecção bacteriana. Em virtude da baixa incidência desta patologia, seu diagnóstico costuma ser tardio, podendo gerar consequências deletérias ao paciente. Os achados clínicos e radiológicos são semelhantes aos da apencidite aguda, e o tratamento é a reintervenção cirúrgica e complementação da apendicectomia, excisando o coto remanescente.

Stump appendicitis is a rare post-appendectomy complication characterized as an inflammation of the remaining appendicular stump due to obstruction of its lumen, usually by a fecalith. Which increases intraluminal pressure, impairs venous drainage, and facilitates subsequent bacterial infection. Due to the low incidence of this pathology, its diagnosis is usually late, and it can have deleterious consequences for the patient. The clinical and radiological findings are similar to those of acute appendicitis, and the treatment is surgical reintervention and complementary appendectomy, excising the remaining stump.

Postoperative pain after endodontic reintervention: a randomized clinical trial

Resumo O objetivo deste ensaio clínico randomizado foi comparar a prevalência e a intensidade da dor pós-operatória em casos de retratamento endodôntico, utilizando instrumentos manuais ou reciprocantes (automatizados). O tempo necessário para desobturação e reinstrumentação do canal radicular também foi avaliado. Quarenta e oito indivíduos possuindo um dente unirradicular tratado endodonticamente e portador de periodontite apical assintomática foram incluídos no estudo. Os pacientes foram aleatoriamente distribuídos em dois grupos (n=24/grupo): retratamento com instrumentos manuais de aço inoxidável ou um sistema reciprocante de níquel-titânio (Reciproc; VDW, Munique, Alemanha). A reintervenção endodôntica foi realizada em duas consultas, sendo aplicada medicação intracanal à base de hidróxido de cálcio por 14 dias, antes da obturação. O tempo clínico gasto com os protocolos de desobturação e reinstrumentação do canal radicular foi registrado com um cronômetro digital. Após cada visita, a intensidade da dor pós-operatória foi avaliada em 12, 24, 48 horas e 7 dias por meio da escala de estimativa numérica (Numerical Rating Scale - NRS). Além do registro da dor, os pacientes foram questionados quanto ao uso de analgésicos. Os dados obtidos foram analisados por testes Qui-quadrado e Mann-Whitney (α=0.05). Não foi detectada diferença significativa entre os grupos quanto à prevalência e intensidade da dor ou uso de analgésicos em nenhum dos períodos avaliados. O tempo clínico foi significativamente menor no grupo reciprocante (18 versus 41 minutos). Pode-se concluir que os instrumentos manuais e reciprocantes foram equivalentes quanto à prevalência e intensidade de dor pós-operatória e uso de analgésicos, mas a desobturação e reinstrumentação do canal radicular foram duas vezes mais rápidas com o sistema reciprocante.

Abstract The present randomized clinical trial compared the prevalence and intensity of postoperative pain in cases of endodontic reintervention using manual or engine-driven reciprocating instruments. As secondary objectives, the analgesic intake and time required for the root canal filling removal and re-instrumentation were also evaluated. Forty-eight individuals with an endodontically treated single-rooted tooth diagnosed with asymptomatic apical periodontitis were included in the study. Patients were randomly assigned to two comparison groups (n=24/group): reintervention with stainless steel manual instruments or a nickel-titanium reciprocating system (Reciproc; VDW, Munich, Germany). The endodontic reintervention was performed in two sessions with a calcium hydroxide-based intracanal medication applied for 14 days before root canal obturation. Working time for the root canal filling removal and re-instrumentation was recorded with a digital stopwatch. After each visit, postoperative pain intensity was assessed at 12, 24, and 48 hours and seven days using the Numerical Rating Scale (NRS). The patients were also asked about analgesic intake. Data were analyzed using Pearson chi-square, T and Mann-Whitney U tests (α=0.05). No significant differences between groups were found regarding the prevalence and intensity of pain or the need for analgesic intake at any time point (P > 0.05). Working time was significantly shorter in the reciprocating group (18 versus 41 minutes). In conclusion, manual and reciprocating instruments achieved the same results in terms of prevalence and intensity of postoperative pain and analgesic intake. However, filling material removal and re-instrumentation of the root canals were more than twice as fast when using the reciprocating system.

The significance of pulmonary veins isolation radiofrequency time and the evolution of left atrium volume on a twelve-year observational follow-up of paroxysmal atrial fibrillation patients

Aims: Pulmonary vein isolation (PVI) is the treatment of choice of paroxysmal atrial fibrillation (PAF). However, radiofrequency delivery at extra-PV sites may be additionally required. We compared clinical and procedural characteristics of patients undergoing PVI alone versus adjunctive extra-PV substrate modification, at first procedure and repeat procedures for AF recurrence. Methods: 587 patients with PAF undergoing radiofrequency (RF) ablation were retrospectively included. Extra-PV ablation was performed in case of sustained AF despite PVI, or at re-do procedures without PV conduction recovery. Demographic, clinical and electrophysiological predictors of survival without reintervention were analysed in patients’ groups having undergone one (G1), two (G2) or three or more procedures (G3). Results: At baseline procedure, PV RF ablation time was shorter in G1 compared to G2/G3 whereas extraPV RF ablation time was greater in G3 compared to G1. The proportion of patients requiring PV reisolation decreased with repeat procedures. Smaller LA before procedure 1 (p1) or p2 was associated with PV reconnection at p2. Conversely larger LA before p1 was associated with extra-PV substrate modification at p2. Late re-do procedure timing (>1yr) was associated with increasing LA volume. Only longer PV and total RF time predicted poorer survival free from AF without re-intervention. Conclusion: Longer PV RF time predicted requirement for re-ablation during follow-up. Smaller LA size predicted an increased probability of PV reconnection and decreased extra-PV substrate modification at p2. LA size decreased in patients undergoing early re-intervention, whereas it increased in patients undergoing re-intervention later on suggesting ongoing remodelling or progression.

Perfil clínico, quirúrgico y epidemiológico de pacientes reintervenidos / Clinical, Surgical and Epidemiological Profile of Reintervened Patients

Introducción: Los pacientes reintervenidos quirúrgicamente no se han caracterizado en el Hospital "Dr. Ambrosio Grillo Portuondo" de Santiago de Cuba. Objetivo: Caracterizar a los pacientes reintervenidos quirúrgicamente según variables de interés. Métodos: Se realizó un estudio transversal, descriptivo y retrospectivo de los pacientes reintervenidos en el citado hospital durante el trienio 2018-2020. La muestra fue de 6279 enfermos. Se analizaron variables epidemiológicas y clínicas quirúrgicas de interés. Los datos se resumieron mediante análisis de frecuencias. Resultados: La tasa de reintervenciones fue de 1,7 por ciento respecto al total de operaciones mayores y el 1,6 por ciento correspondió a la cirugía abdominal. Predominó el grupo de edades entre 46 y 60 años y el sexo femenino con 37,8 por ciento y 55 por ciento, respectivamente. La operación inicial fue realizada de urgencia en el 91 por ciento de los casos por apendicitis aguda y oclusión intestinal (21,7 por ciento y 18 por ciento). El 70,2 por ciento de la casuística se reintervino 4 días después por absceso intrabdominal (39,6 por ciento) y dehiscencia de sutura anastomótica (20,7 por ciento). La relaparotomía a demanda (98,1 por ciento) fue la mayormente efectuada con 18 por ciento de aplicación de la técnica de abdomen abierto. La mortalidad fue de 28 por ciento y la causa de muerte fue el choque séptico en un 80,6 por ciento. Conclusiones: Los pacientes reintervenidos constituyeron un problema de salud hospitalario que impactó en el perfil de morbilidad y mortalidad de la cirugía abdominal(AU)

Introduction: Surgical reintervention patients have not been characterized at Dr. Ambrosio Grillo Portuondo Hospital of Santiago de Cuba. Objective: To characterize the surgically intervened patients according to variables of interest. Methods: A cross-sectional, descriptive and retrospective study was carried out with the patients surgically reintervened in the aforementioned hospital during the 2018-2020 triennium. The sample consisted of 6279 patients. Epidemiological and surgical-clinic variables of interest were analyzed. Data were summarized by frequency analysis. Results: The reintervention rate was 1.7 percent compared to the total number of major operations, while 1.6 percent corresponded to abdominal surgery. There was a predominance of the age group 46-60 years and the female sex predominated, accounting for 37.8 percent and 55 percent, respectively. The initial operation was performed urgently in 91 percent of the cases, due to acute appendicitis and intestinal occlusion, accounting for 21.7 percent and 18 percent, respectively. 70.2 percent of the cases were reintervened four days later for intraabdominal abscess (39.6 percent) and anastomotic suture dehiscence (20.7 percent). On-demand relaparotomy (98.1 percent) was the most performed procedure, with 18 percent of application of the open-abdomen technique. Mortality represented 28 percent of cases, while the most frequent cause of death was septic shock, accounting for 80.6 percent of deaths. Conclusions: The reintervened patients constituted a hospital health concern that impacted on the morbidity and mortality profile of abdominal surgery(AU)

Epidemiology of Dupuytren disease and Patients Undergoing Selective Fasciectomy / Epidemiologia da doença de Dupuytren e de pacientes submetidos a fasciectomia seletiva

Abstract Objective To describe the epidemiological and clinical profile of patients with Dupuytren disease treated by selective fasciectomy and the factors associated with the severity of the disease. Methods Retrospective descriptive observational study involving 247 patients with Dupuytren disease, from 2013 to 2019. Multivariate logistic regression was performed for data analysis. Results Most patients were male (83.8%), self-declared white (65.2%), alcoholics (59.6%) and 49% were smokers, with a mean age of 66 ± 9 years old, with 77.2% presenting symptoms of the disease after the age of 51 years old. Approximately 51.9, 29.6 and 17.3%, respectively, had arterial hypertension, diabetes mellitus and dyslipidemia comorbidities. Bilateral involvement of the hands was observed in 73.3% of the patients. The rate of intra- and post-selective fasciectomy complications was of 0.6 and 24.3%, respectively, with 5.2% of the patients needing reintervention after 1 year of follow-up. After multivariate analysis, males were associated with bilateral involvement of the hands (odds ratio [OR] = 2.10; 95% confidence interval [CI]: 1.03-4.31) and with a greater number of affected rays (OR = 3.41; 95% CI: 1.66-7.03). Dyslipidemia was associated with reintervention (OR = 5.7; 95% CI = 1.03-31.4) and bilaterality with a higher number of complications (35.7 versus 19.7%). Conclusion A low rate of reintervention and operative complications was observed in patients with Dupuytren disease treated by selective fasciectomy. Male gender was associated with severe disease (bilaterality and more than two affected rays), and dyslipidemia with reintervention.

Resumo Objetivo Descrever o perfil epidemiológico e clínico dos pacientes com doença de Dupuytren tratados por fasciectomia seletiva e os fatores associados com a gravidade da doença. Metodologia Estudo observacional descritivo retrospectivo envolvendo 247 pacientes com doença de Dupuytren, no período de 2013 a 2019. Foi realizada regressão logística multivariada para análise dos dados. Resultados A maioria dos pacientes era do sexo masculino (83,8%), autodeclarados brancos (65,2%), etilistas (59,6%), e 49% eram tabagistas. A média de idade foi de 66 ± 9 anos, sendo que 77,2% apresentaram os sintomas da doença após os 51 anos. Aproximadamente 51,9, 29,6, e 17,3%, respectivamente, apresentaram hipertensão arterial, diabetes mellitus e dislipidemia. O acometimento bilateral das mãos foi observado em 73,3% dos pacientes. A taxa de complicações intra- e pós-fasciectomia seletiva foi de 0,6 e 24,3%, respectivamente, sendo que 5,2% dos pacientes necessitaram de reintervenção após 1 ano de acompanhamento. Após análise multivariada, o sexo masculino foi associado com acometimento bilateral das mãos (odds ratio [OR] = 2,10; intervalo de confiança [IC] 95%: 1,03-4,31) e com maior número de raios acometidos (OR = 3,41; IC 95%: 1,66-7,03). A dislipidemia foi associada com a reintervenção (OR = 5,7; CI 95%: 1,03-31,4) e a bilateralidade com maior número de complicações (35,7% versus 19,7%). Conclusão Foi observada uma baixa taxa de reintervenção e complicações operatórias nos pacientes com doença de Dupuytren tratados por fasciectomia seletiva. O sexo masculino foi associado com o quadro grave da doença (bilateralidade e mais de dois raios acometidos), e a dislipidemia com a reintervenção.

Follow-up and further intervention for postoperative pulmonary venous obstruction of total anomalous pulmonary venous connection / 中华胸心血管外科杂志

Objective:Postoperative venous obstruction (PVO) is the most severe complication of total anomalous pulmonary venous connection (TAPVC), and facing challenging re-intervention with high mortality. We aimed to review and analyze the follow-up and management of postoperative PVO in our center.Methods:We conducted a retrospective study of the patients with isolated TAPVC admitted in our center from October 2013 to October 2019. All available data and images of PVO patients were reviewed, such as the initial perioperative medical records, patients’ follow-up records, results of patients’ echo and CT angiography. Re-intervention including hybrid technique, sutureless technique, and patch augmentation, were carried out for postoperative PVO patients. The results were reviewed and analyzed to find the risk factors for adverse prognosis.Results:A series of 174 isolated TAPVC patients were admitted in our center and 169 received surgical treatment and 26 (26/169, 15.4%) had postoperative PVO. The diagnosis was made at a median time of 11.5 (0-77) weeks after initial operation and within 6 months of surgery in 22 (22/26, 84.6%) of the 26 patients. The subtype of TAPVC patients with postoperative PVO were: supracardiac 11 cases (11/26, 42.3%), cardiac 7 cases (7/26, 26.9%), infracardiac 5 cases (5/26, 19.2%), and mixed 3 cases (3/26, 11.5%). Bilateral obstruction and stenosis with diffusely small pulmonary veins were in 12 (12/26, 46.2%) and 3 cases (3/26, 11.5%) respectively. PVO progressed to worse condition in all the 26 cases during follow-up period. 8 (8/26, 30.8%) postoperative PVO patients underwent 10 re-interventions: one cases had 3 re-interventions. Five-year survival for patients with postoperative PVO was worse than those without postoperative PVO ( HR=6.46, 95% CI: 2.34-17.85, P<0.01). Risk factors for death or re-intervention in postoperative PVO patients were earlier presentation after TAPVC repair ( HR=0.85, 95% CI: 0.73-0.99, P=0.04) and an increased number of lung segments affected by obstruction ( HR=1.74, 95% CI: 1.01-2.99, P=0.04). Conclusion:Risk factors for death or re-intervention in postoperative PVO patients were earlier presentation after TAPVC repair and an increased number of lung segments affected, which should be focused on during strict follow-up period. Early re-intervention should be taken before irreversible secondary changes occur in these patients.

Evaluation of mid-term outcomes of pulmonary valve replacement surgery after repair of tetralogy of Fallot / 中国胸心血管外科临床杂志

@#Objective    To evaluate mid-term outcomes of pulmonary valve replacement surgery after repair of tetralogy of Fallot. Methods    A total of 73 patients with repaired tetralogy of Fallot who underwent pulmonary valve replacement surgery in our hospital from January 2010 to January 2020 were enrolled, including 42 males and 31 females. The median age was 3.9 (0.2-42.8) years at initial repair and 20.0 (2.0-50.0) years at pulmonary valve replacement. The clinical data of the patients were recorded and analyzed. Results    There was no death in postoperative 30 d. The average follow-up time was 35.6±28.5 months, and no death occurred during the follow-up. One patient underwent a second reintervention after initial pulmonary valve replacement. The 1- and 5-year survival rates were both 100.0%, the 1- and 5-year reintervention-free rates were both 100.0%, and the 1- and 5-year valve failure-free rates were 100.0% and 67.1%. There was no significant difference in valve failure-free rates between different age groups (P=0.49) and different type of valve groups (P=0.74). The right (P=0.006) and left (P=0.002) ventricular ejection fractions were significantly improved, and the QRS duration was shortened after pulmonary valve replacement (P=0.006). Conclusion    Mid-term outcomes of surgical pulmonary valve replacement were satisfactory in patients with repaired tetralogy of Fallot, while the long-term effects should be further emphasized in clinical practice.

Outcomes after Surgical Repair of Thoracoabdominal Aortic Aneurysm with Distal Aortic Dissection:DeBakey Type Ⅰ versus Type Ⅲ / 中国医学科学院学报

To evaluate the early and mid-term results after surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with DeBakey typeⅠor Ⅲ aortic dissection. The clinical data of 130 patients who underwent TAAA repair for chronic DeBakey typeⅠ(groupⅠ, =47)or type Ⅲ(group Ⅲ, =83)aortic dissections in our center between January 2009 and December 2017 were retrospectively analyzed.Early postoperative results,midterm survival,and re-interventions were compared between these two groups. The 30-day mortality rate was 6.9%(=9)in the overall cohort,with no statistic difference between groupⅠand group Ⅲ(10.6% 4.8%;=0.803, =0.370).The incidence of major adverse events(38.3% 51.8%;=2.199, =0.138),5-year actuarial survival rate [(81.7±5.9)% (87.2±4.2)%;=0.483, =0.487],and 5-year actuarial freedom from all reinterventions [(84.5±6.7)% (85.5±4.8)%;=0.010, =0.920] showed no significant differences between these two groups. The early and mid-term outcomes after surgical repair of TAAA are similar for DeBakey typeⅠ and type Ⅲ patients.However,studies with larger sample sizes are still required.

Clinical research of reintervention for children with postoperative valve disease / 中华胸心血管外科杂志

Objective The purpose of this report was to discuss and evaluate the timing and outcome of reintervention for children with postoperative valve disease.Methods The clinical data of 139 patients with postoperative valve disease who received reintervention at SCMC from Sep.2004 to Mar.2019 were retrospectively analysed,including 85 males and 54 females.The age ranged from 8-175 months,and the weight ranged from 6.2-75.9 kg.With a mid-long term follow-up (2-133 months),the echocardiography result showed:40 cases of aortic valve disease,49 cases of mitral valve disease,32 cases of tricuspid valve disease and 18 cases of pulmonary valve disease.All patients underwent reintervetion treatment,the distribution of reintervention methods were shown as follow:47 cases of valve replacement,40 cases of valvuloplasty,23 cases of annuloplasty and 29 case of valve reconstuction.Results There were 6 in-hospital deaths with a mortality of 4.3％.The death cases included 2 cases of aortic disease,2 cases of mitral disease,1 case of tricuspid disease and 1 case of pulmonary disease.The early postoperative causes of death were acute myocardial failure,multiple organ failure and severe hyoxemia.Three delayed deaths occurred 8-26 months after operation because of cardiac insufficiency and cardiac shock.All survivors were under a follow-up of 4-148 months.The echocardiography showed the velocity of 92.3％ valve stenosis patients had decreased significantly (P ＜0.05);the insufficient grades of 84.9％ patients had reduced and maintained under morderate degree.6 cases occurred aggravated insufficiency or stenosis and received reoperation in mid-term follow-up included 3 cases of aortic valve,2 cases of pulmonary valve and 1 case of mitral valve.The cardiac function of survival patients has been improved after reintervtion,83.1％ patients maintained cardiac function at NYHA Ⅰ / Ⅱ at follow-up.The long-term survival rates of 4 valve disease were all over 90％.Conclusion The anatomical structure of chilidren's valve is complicated and various,valve insufficiency and stenosis often occured after operation.The timing of reintervetion should focus on clinic symptom and cardiac function.The operation should be individually designed according to valve anatomy,which could effectly correct abnormal valve structure,promote cardiac function and improve living quality.

Clinical research of reintervention for children with postoperative valve disease / 中华胸心血管外科杂志

Objective@#The purpose of this report was to discuss and evaluate the timing and outcome of reintervention for children with postoperative valve disease.@*Methods@#The clinical data of 139 patients with postoperative valve disease who received reintervention at SCMC from Sep. 2004 to Mar. 2019 were retrospectively analysed, including 85 males and 54 females. The age ranged from 8-175 months, and the weight ranged from 6.2-75.9 kg. With a mid-long term follow-up (2-133 months), the echocardiography result showed: 40 cases of aortic valve disease, 49 cases of mitral valve disease, 32 cases of tricuspid valve disease and 18 cases of pulmonary valve disease. All patients underwent reintervetion treatment, the distribution of reintervention methods were shown as follow: 47 cases of valve replacement, 40 cases of valvuloplasty, 23 cases of annuloplasty and 29 case of valve reconstruction.@*Results@#There were 6 in-hospital deaths with a mortality of 4.3%. The death cases included 2 cases of aortic disease, 2 cases of mitral disease, 1 case of tricuspid disease and 1 case of pulmonary disease. The early postoperative causes of death were acute myocardial failure, multiple organ failure and severe hyoxemia. Three delayed deaths occurred 8-26 months after operation because of cardiac insufficiency and cardiac shock. All survivors were under a follow-up of 4-148 months. The echocardiography showed the velocity of 92.3% valve stenosis patients had decreased significantly (P<0.05); the insufficient grades of 84.9% patients had reduced and maintained under morderate degree. 6 cases occurred aggravated insufficiency or stenosis and received reoperation in mid-term follow-up included 3 cases of aortic valve, 2 cases of pulmonary valve and 1 case of mitral valve. The cardiac function of survival patients has been improved after reintervtion, 83.1% patients maintained cardiac function at NYHA Ⅰ/Ⅱ at follow-up. The long-term survival rates of 4 valve disease were all over 90%.@*Conclusion@#The anatomical structure of chilidren’s valve is complicated and various, valve insufficiency and stenosis often occured after operation. The timing of reintervetion should focus on clinic symptom and cardiac function.The operation should be individually designed according to valve anatomy, which could effectly correct abnormal valve structure, promote cardiac function and improve living quality.

Prise en charge des patients nécessitant une réintervention cardiaque valvulaire: Expérience du service de cardiologie du CHU d'Oran / Management of patients requiring a reintervention of the heart valve: Experience of the cardiology department of University Hospital Center of Oran

Introduction - Les cardiopathies valvulaires demeurent fréquentes malgré l'amélioration des conditions sanitaires qui ont permis la réduction de l'incidence du rhumatisme articulaire aigu (RAA). Les indications chirurgicales et interventionnelles se sont élargies et nous opérons aujourd'hui à des stades précoces voire asymptomatiques. Une réintervention chirurgicale valvulaire est nécessaire dans environ 15% des cas au cours de l'évolution d'une valvulopathie opérée. L'objectif de notre étude est de déterminer la fréquence des réinterventions valvulaires et d'identifier les principales indications de ces réinterventions. Méthodes - Il s'agit d'une étude rétrospective descriptive, portant sur 45 patients, admis au service de cardiologie du Centre Hospitalo-Universitaire (CHU) d'Oran, de janvier 2011 à juillet 2013, et présentant une valvulopathie déjà opérée nécessitant une autre réintervention chirurgicale valvulaire. Résultats - La moyenne d'âge est de 41 ans, 73% des patients sont des femmes et 27% des hommes (Sex ratio de 0,37). La plupart de nos patients sont symptomatiques (dyspnée stade II de la NYHA). Les réinterventions intéressent la valve mitrale dans 69% des cas, la valve aortique dans 37% des cas et la valve tricuspide dans 35%. Nous avons constaté l'importance des insuffisances aortiques et tricuspides négligées lors de la première intervention (31% et 62% respectivement). Le délai moyen entre les deux interventions, tout type confondu, est de 21 ans. Conclusion - Les réinterventions cardiaques peuvent survenir au cours de l'évolution d'une valvulopathie. Une bonne évaluation cardiaque initiale des valvulopathies lors d'une chirurgie portant sur la valve mitrale ou aortique est indispensable pour pallier au problème d'une réintervention pour des valvulopathies négligées.

Background - Valvular heart disease still common despite improved health conditions that have reduced the rheumatic fever incidence. Surgical and interventional indications have expanded and today we operate at early stages, sometimes even an asymptomatic stage. Valvular reoperation is required in 15% of cases during the evolution of an operated valve disease. The aim of our study is to determine the frequency of valvular reoperations and identify the main indications of these reinterventions. Methods - This is a retrospective study included 45 patients who were admitted to the cardiology department of University Hospital center of Oran, from January 2011 to July 2013 and who had previously operated valvular disease requiring another surgical valvular reoperation. Results - The mean age is 41 years. 73% of patients are women and 27% are men. 95% of patients are symptomatic (NYHA dyspnea stage II). Reinterventions affected the mitral valve in 69% of cases, the aortic valve in 37% cases and the tricuspid valve in 35%. We reporte the importance of neglected aortic and tricuspid regurgitation during the first intervention (31% and 62% respectively). The average time between the two interventions, all types combined, is 21 years. Conclusion - Cardiac reoperations may occur during the course of valvular heart disease. A good initial cardiac evaluation before surgery on the mitral or aortic valve is essential to overcome the problem of neglected valvular disease reoperation.

Clinical research of reintervention for children with pulmonary venous restenosis / 中华胸心血管外科杂志

Objective The purpose of this report is to summarize and evaluate the clinical effect and experience of re-intervention for children with pulmonary venous restenosis.Methods The clinical data of 53 patients with pulmonary venous restenosis who received reintervention at SCMC from September 2009 to January 2018 were retrospectively analysed, including 34 males and 19 females with mean age of(15.1 ±13.2)months(2-77 months) and mean weight of(7.9 ±3.3)kg(3.7 -17.3 kg).The mean preoperative pulmonary venous velocity was(2.28 ±0.40)m/s(1.89 -3.07 m/s).Primary disease in-cluded 43 cases of total anomalous of pulmonary venous drainage(14 supracardiac type, 20 infracardiac type, 2 intracardiac type and 7 mix type), 8 cases of partial anomalous of pulmonary venous drainage and 2 cases of primary pulmonary venous ste-nosis.The distribution of reintervention methods were shown as follow:34 cases of sutureless technique(21 cases with pedicle pericardium and 13 cases with left auricle tissue), 10 cases of bovine pericardium enlargement, 5 cases of blunt enlargement, 3 cases of balloon dilatation and 1 case of stent implantation.Results The early postoperative pulmonary venous velocity was (1.12 ±0.23) m/s.There were 4 in-hospital deaths with a mortality of 7.5％.49 survivors were under a follow-up of 3-98 months.The echocardiography showed pulmonary venous anastomosis and diameter have grown after reintervetion with a mean growth speed of(0.022 ±0.014)cm/month(P<0.05) and a mean velocity of(1.25 ±0.28)m/s;4 patients occured varying degrees of pulmonary venous obstruction( >1.6 m/s) but no one need reoperation at present.More than 90％ patients exhibi-ted an improvement of NYHA functional class from Ⅲ or Ⅳ preoperatively to Ⅰ or Ⅱ at follow-up.Conclusion Pulmonary venous restenosis is a common complication after primary pulmonary malformations operation .The reintervetion should be per-formed in early period of pulmonary venous obstruction .Pulmonary venous anastomoses after sutureless technique , bovine peri-cardium enlargement and blunt enlargement have grown obviously; although balloon dilatation has a good effect at early period of postoperation, it also has a high restenosis rate and needs a strict mid-and long-term follow-up.

El dilema de las reintervenciones quirúrgicas / The dilema of surgical reinterventions

RESUMEN Introducción: En la actualidad, la diversidad de criterios relacionados con las reintervenciones quirúrgicas constituyen un verdadero problema científico, por cuanto, resulta de gran importancia profundizar en torno a los principales aspectos cognoscitivos relacionados con este tema a fin de elevar la calidad asistencial y, con esa premisa, el índice de supervivencia, sobre todo en la población envejecida como grupo vulnerable. Objetivos: Identificar los factores que permitan reconocer las condiciones modificables que disminuyan las complicaciones y fallecimientos de los enfermos tributarios de un nuevo tratamiento quirúrgico para salir adelante y sobrevivir. Métodos: Revisión digital de publicaciones actualizadas en español e inglés en bases de datos: Google, Redalyc, PubMed, Medline, Lilacs, Elsevier. Resultados: Las complicaciones posquirúrgicas y las que requieren una reintervención en particular son de origen multifactorial. No existe una definición y una clasificación estandarizada de las complicaciones posquirúrgicas para notificarlas. Las más utilizadas son las objetivas de Clavien Dindo y Accordeon, basadas en la estratificación del tratamiento requerido, el riesgo y gravedad. Conclusiones: A pesar de que el gran avance tecnológico actual en los métodos diagnósticos y terapéuticos ha permitido que los pacientes con complicaciones posquirúrgicas sean reintervenidos con mayor seguridad, la morbilidad y la mortalidad a causa de estas continúan elevadas(AU)

ABSTRACT Introduction: Nowadays, the diverse criteria related to surgical reinterventions are a real scientific problem since it is very important to delve into the main cognitive aspects associated to this topic in order to raise the quality of medical assistance and thus the survival index in the old population as a vulnerable group. Objectives: To identify the factors that allow recognizing the modifiable conditions that lead to less complications and deaths of patients undergoing a new surgical treatment. Methods: Search of updated publications in English and Spanish made in Goggle, Redalyc, PubMed, Medline, Lilacs and Elsevier databases. Results: The postsurgical complications and those requiring surgical reintervention in particular are of multifactoral origin. There is neither one single definition nor one standardized classification of the postsurgical complications to notify them. The most used objective classifications are Claven Dindo and Accordeon, based on the stratification of the required treatment, the risk and the severity. Conclusions: In spite of the fact that the great technological advances in the diagnostic and therapeutic methods have allowed the reoperation of complicated patients with higher margin of safety, morbidity and mortality caused by such complications are still high(AU)

Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair / Conversão tardia para cirurgia aberta em um aneurisma roto da aorta abdominal após reparo endovascular

Abstract Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.

Resumo Apesar dos avanços tecnológicos, os desfechos de longo prazo do reparo endovascular de aneurismas da aorta abdominal (endovascular aortic aneurysm repair - EVAR) ainda são objeto de debate. Embora a maioria das falhas de endoenxerto após EVAR possam ser corrigidas com técnicas endovasculares, conversão para cirurgia aberta ainda pode ser necessária. Um paciente de 70 anos de idade, do sexo masculino, apresentou-se no serviço de emergência com dor abdominal. Duas vezes, dois e quatro anos após o primeiro reparo, um enxerto foi colocado sobre uma porção não adesiva do stent devido a endoleak tipo Ia. Na mais recente hospitalização, a tomografia computadorizada mostrou endoleak tipo III e ruptura de um saco aneurismático. Nesta ocasião, o paciente foi submetido a conversão tardia para cirurgia aberta. A falha foi tratada com preservação total do corpo principal do enxerto endovascular e interposição de um enxerto tipo Dacron bifurcado. Este caso demonstra que a vigilância radiográfica ao longo de toda a vida deveria ser considerada nesse subgrupo de pacientes. Conversão tardia para cirurgia aberta após EVAR de aneurismas rotos da aorta abdominal pode ser realizada com segurança.

Unplanned re-intervention within 30 days after pediatric cardiac surgery / 中国胸心血管外科临床杂志

@#Objective     To recognize the risk factors of unplanned re-interventions within 30 days after pediatric cardiac surgery and evaluate the outcome of re-interventions. Methods     We retrospectively analyzed the clinical data of 202 children in Fuwai Hospital between January 1, 2015 and August 31, 2017. There were 115 males and 87 females at average age of 32.4 months with range of 3 days to 14 years. Results     There were 202 children who underwent unplanned re-intervention during 30 days post-operation, including 54 re-adjustments of pulmonary blood flow, 34 re-corrections for residual cardiac abnormalities, 28 cardiopulmonary resuscitations, 38 for coagulation problems, 19 pericardial drainages, 11 palliative re-operations to deliver heart load and 6 diaphragmatic folds and 12 others. The mortality rate among children who underwent unplanned re-inventions after cardiac surgery was 10.9% (22/202). It was much higher than those free from re-interventions (0.7%). Time of mechanical ventilation was 284.3 (11–2 339) h, and mean ICU stay was 17.7 (1–154) d, significantly longer than those free from re-interventions at the same period. Conclusion     Unplanned re-interventions after pediatric cardiac surgery is associated with higher mortality rate and longer recovery time. Early identifying risk factors and re-intervention can reduce the complications and improve the prognosis.

A Case of Open Surgery for Endoleak after Thoracic Endovascular Aortic Repair of the Aortic Arch / 日本心臓血管外科学会雑誌

A 72-year-old woman underwent thoracic endovascular aortic repair (TEVAR) for an aortic arch aneurysm at a previous hospital. During follow-up, although the aneurysm was found to have become bigger, no further treatments were given, except for conservative follow-up. The patient sought a second opinion and thus visited our hospital. Enhanced computed tomography (CT) revealed a type I endoleak that required repair. Total arch replacement with removal of the partial stent-graft system was performed under deep hypothermic circulatory arrest. The patient made a steady progress postoperatively and was discharged without any complications. Endovascular repair is minimally invasive and frequently used in various medical facilities but carries a considerably high risk of reintervention. Treatment strategies for aortic aneurysm, including open surgery, should be carefully chosen.

Reintervenciones por fracaso de la miotomía de Heller por acalasia esofágica / Reintervention after failed Heller myotomy for esophageal achalasia

Introducción: la cardiomiotomía de Heller asociada al proceder antirreflujo descrito por Dor constituye el tratamiento de elección en los pacientes con acalasia esofágica; sin embargo, las causas del fracaso del tratamiento aún son controversiales. Objetivo: describir las causas del fracaso de la miotomía de Heller en pacientes operados por acalasia esofágica y la evolución clínica de los pacientes reintervenidos. Métodos: se realizó un estudio descriptivo, retrospectivo y longitudinal de una serie de pacientes reintervenidos por fracaso de la miotomía de Heller en el Centro Nacional de Cirugía de Mínimo Acceso desde enero de 2010 hasta diciembre de 2016. Resultados: se les realizó miotomía de Heller a 253 pacientes con diagnóstico de acalasia esofágica. De ellos, 7 (2,7 por ciento) fueron reintervenidos por recurrencia de los síntomas, 4 (1,5 por ciento) fueron operados inicialmente en la institución y el resto fueron remitidos de otras instituciones del país. La edad media fue de 41 ± 15 años (rango 20-59). Los síntomas más frecuentes fueron la disfagia posoperatoria y la pérdida de peso (100 por ciento). El tiempo de recurrencia de los síntomas después de la primera operación fue de 6-12 meses en 4 (57 por ciento), de 12 a 18 meses en 1 (16 por ciento) y de 18 a 24 en 2 (33 por ciento) pacientes. Conclusiones: la miotomía incompleta fue la causa principal de reintervención. La remiotomia laparoscópica con o sin fundoplicatura fue la técnica quirúrgica de elección para estos pacientes los cuales tuvieron una evolución clínica excelente o buena en el posoperatorio(AU)

Introduction: Heller's cardiomyotomy associated with the antireflux procedure described by Dor is the treatment of choice in patients with esophageal achalasia. However, the causes of treatment failure are still controversial. Objective: To describe the causes of failure of Heller's myotomy in patients operated for esophageal achalasia and the clinical progress of patients who required another surgery. Methods: A descriptive, retrospective and longitudinal study was performed in a series of patients who required another surgery due to failed Heller's myotomy at the National Center for Minimally Invasive Surgery from January 2010 to December 2016. Results: Heller's myotomy was performed in 253 patients diagnosed with esophageal achalasia. Among these patients, 7 (2.7 percent) required another surgery due to the relapse of symptoms, 4 (1.5 percent) were initially operated at the institution, and the rest were referred from other institutions in the country. The average age was 41±15 years (range 20-59). The most frequent symptoms were postoperative dysphagia and weight loss (100 percent). The time of symptoms relapse after the first surgery was 6-12 months in 4 patients (57 percent), 12-18 months in 1 (16 percent) and 18-24 months in 2 (33 percent) patients. Conclusions: Incomplete myotomy was the main cause of reintervention, laparoscopic myotomy with or without fundoplication being the surgical technique of choice for these patients, who had an excellent or good postoperative clinical evolution(AU)

How Long Can the Next Intervention Be Delayed after Balloon Dilatation of Homograft in the Pulmonary Position?

BACKGROUND AND OBJECTIVES: We investigated the effectiveness of balloon dilatation of homograft conduits in the pulmonary position in delaying surgical replacement. SUBJECTS AND METHODS: We reviewed the medical records of patients who underwent balloon dilatation of their homograft in the pulmonary position from 2001 to 2015. The pressure gradient and ratio of right ventricular pressure were measured before and after the procedure. The primary goal of this study was to evaluate the parameters associated with the interval to next surgical or catheter intervention. RESULTS: Twenty-eight balloon dilations were performed in 26 patients. The median ages of patients with homograft insertion and balloon dilatation were 20.3 months and 4.5 years, respectively. The origins of the homografts were the aorta (53.6%), pulmonary artery (32.1%), and femoral vein (14.3%). The median interval after conduit implantation was 26.7 months. The mean ratio of balloon to graft size was 0.87. The pressure gradient through the homograft and the ratio of right ventricle to aorta pressure were significantly improved after balloon dilatation (p<0.001). There were no adverse events during the procedure with the exception of one case of balloon rupture. The median interval to next intervention was 12.9 months. The median interval of freedom from re-intervention was 16.6 months. Cox proportional hazards analysis revealed that the interval of freedom from re-intervention differed only according to origin of the homograft (p=0.032), with the pulmonary artery having the longest interval of freedom from re-intervention (p=0.043). CONCLUSION: Balloon dilatation of homografts in the pulmonary position can be safely performed, and homografts of the pulmonary artery are associated with a longer interval to re-intervention.

Recent Advances of Biliary Stent Management

Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Even we employed metallic stents which contributed to higher rates and longer durations of patency, and occlusion of covered metallic stents now occurs in about half of all patients during their survival. We investigated the complication and patency rate for the removal of covered metallic stents, and found that the durations were similar for initial stent placement and re-intervention. In order to preserve patient quality of life, we currently recommend the use of covered metallic stents for patients with malignant biliary obstruction because of their removability and longest patency duration, even though uncovered metallic stents have similar patency durations.

The Outcome Analysis of Reintervention for the Infrainguinal Bypasses

Retrospective analysis of reinterventions for the failed or failing infrainguinal bypass grafts were carried out to observe the outcomes and to analyze the factors impacting the outcomes of the reinterventions. During the period of 5 years, 30(16.6%) reinterventions were performed at Department of Surgery, Kyungpook National University Hospital following 181 infrainguinal bypasses for 150 patients with chronic arterial occlusive disease. The indications for the reinterventions were recurrent claudication (23.3%), rest pain (60%), ulcer or gangrene (10%), and graft infection (3.3%). The angiographic findings were categorized as graft occlusion(16), stenosis of the bypass graft or anastomotic sites(8) and inflow or run-off artery occlusive lesion(5). The reintervention procedures were surgical in 27 limbs and percutaneous transluminal angioplasty(PTA) in 3 limbs. To observe the outcomes of reinterventions, the initial technical success, requirement of further interventions, and overall limb salvage rates were analyzed according to the time intervals between primary bypasses and reintervention, reintervention procedures and types of the lesions. The overall limb salvage rates after 30 reinterventions were 83.3% with mean follow-up of 28.6 months. We observed the limb salvage rate was lower after reintervention for the patients with total graft occlusion compared to stenotic lesion(75 % vs 100% p=0.26 ), prosthetic graft occlusion(75%), infrapopliteal bypass as a primary bypass, and patients who underwent early within 30 days reintervention after primary bypasses(60%). However, further investigation is required to get statistical acceptance.