Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet.

OBJECTIVE: To determine the durability of repair of a bicuspid aortic valve with leaflet prolapse, and to identify factors associated with repair failure. METHODS: From November 1988 to January 1997, 94 patients with a bicuspid aortic valve and regurgitation from leaflet prolapse had aortic valve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder underwent mid-leaflet plication of the prolapsing leaflet. Mean age was 38 +/- 10 years and 93% were male. Median follow-up was 5.5 years (range 0.2-9 years). Factors associated with aortic valve competence and durability were identified by multivariable logistic and hazard function analyses. RESULTS: Early valve competence was more difficult to achieve in patients with large, poor functioning ventricles (P = 0.02). Aortic valve reoperation was necessary in 12 patients that included three re-repairs and nine aortic valve replacements. Freedom from reoperation was 95, 87 and 84% at 1, 5 and 7 years, respectively. The instantaneous risk of reoperation was highest immediately after operation, and fell rapidly to approximately 2% per year and less after 2 years. The only risk factor identified was the presence of residual aortic regurgitation (trace to mild in 35 cases) on immediate intraoperative post-repair transesophageal echocardiography. Late aortic regurgitation did not progress detectably across time (P = 0.3). There were no deaths, early or late. CONCLUSION: Bicuspid aortic valve repair for prolapsing leaflet is a safe procedure with good intermediate-term outcome. However, any residual aortic regurgitation jeopardizes repair durability and initial repair achievement is more difficult in patients with dilated, poor functioning ventricles.

Two internal thoracic artery grafts are better than one.

OBJECTIVE: Does the use of bilateral internal thoracic artery (ITA) grafts provide incremental benefit relative to the use of a single ITA graft? METHODS: We conducted a retrospective, nonrandomized, long-term (mean follow-up interval of 10 postoperative years) study of patients undergoing elective primary isolated coronary bypass surgery who received either single (8123 patients) or bilateral ITA grafts (2001 patients), with or without additional vein grafts. Multiple statistical methods including propensity score matching, and multivariable parsimonious and nonparsimonious risk factor analyses were used to address the issues of patient selection and heterogeneity. RESULTS: In-hospital mortality was 0.7% for both the bilateral and single ITA groups. Survival for the bilateral ITA group was 94%, 84%, and 67%, and for the single ITA group 92%, 79%, and 64% at 5, 10, and 15 postoperative years, respectively (P <.001). Death, reoperation, and percutaneous transluminal coronary angioplasty were more frequent for patients undergoing single rather than bilateral ITA grafting, and this observation remained true despite multiple adjustments for patient selection, sampling, and length of follow-up. The differences between the bilateral and single ITA groups were greatest in regard to reoperation. The extent of benefit of bilateral ITA grafting varied according to patient-related variables, but no patient subsets were identified for whom single ITA grafting could be predicted to provide an advantage. CONCLUSIONS: Patients who received 2 ITA grafts had decreased risks of death, reoperation, and angioplasty.

Pancreatic trauma: a ten-year multi-institutional experience.

Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.

Small-bowel diverticulosis: perceptions and reality.

BACKGROUND: Small-bowel diverticulosis is a rare entity that can be discovered incidentally during celiotomy, endoscopy, or radiographic imaging studies. The reported complication rate is low, giving rise to the current recommendation not to treat uncomplicated small-bowel diverticula. STUDY DESIGN: A retrospective review was performed of patients with small-bowel diverticulosis seen during 23 years at three major institutions. RESULTS: Two hundred eight patients were identified. Diverticula were located in the duodenum in 79 percent; in the jejunum or ileum in 18 percent; and in duodenum, jejunum, and ileum in 3 percent. Complications developed in 42 of the 208 patients (20 percent) including bleeding in 14, diverticulitis with perforation and abscess formation in 12, and malabsorption in 8. When assessed by location, jejunoileal diverticula were more likely to have complications than duodenal diverticula: 46 percent compared to 13 percent (p < .01). Bleeding accounted for 52 percent of the duodenal complications compared to 12 percent of the jejunoileal complications (p < 05). Jejunoileal diverticula were more likely to perforate and develop abscesses (21 percent compared to 1.2 percent; p < .001). CONCLUSIONS: The low incidence of complications associated with duodenal diverticula justifies a nonoperative approach. The higher complication rate associated with jejunoileal diverticula will be necessary to define that approach more exactly.

Computed tomography: an unreliable indicator of pancreatic trauma.

Computed tomography (CT) is currently the modality of choice in evaluating pancreatic injury in patients suffering abdominal trauma who do not require immediate exploration. The purpose of this study was to determine the reliability of initial CT scanning in the detection of pancreatic trauma. A retrospective review was performed of all patients admitted to two Level 1 trauma centers over a 10-year period. Those patients identified with pancreatic injury who underwent initial evaluation with CT scanning were reviewed for clinical course and comparison of CT results with findings at laparotomy. Seventy-two patients of 16,188 admissions (0.4%) were identified with pancreatic injury. Mechanism of injury was blunt in 27 (37%), gunshot wound in 32 (45%), and stab wound in 13 (18%). There were 18 (25%) grade I, 32 (45%) grade II, 16 (22%) grade III, and 5 (7%) grade IV pancreatic injuries. Seventeen of the 72 patients with pancreatic injury underwent initial abdominal CT. The pancreas was normal on CT in 9 and of these, 8 underwent exploration, most commonly secondary to splenic injury. Three were found to have grade I pancreatic injury, two grade II, and three grade III, which required distal pancreatectomy. The pancreas was abnormal on CT in eight patients, and of these three underwent exploration. One patient had an injury upgraded from II on CT to III at exploration and underwent distal pancreatectomy. The mean pancreatic injury by CT was 0.45 versus 2.0 on exploration (P < 0.001). Injury to the pancreas following blunt trauma is rare. Computed tomography will often miss or underestimate pancreatic injuries that require operative treatment, and normal findings on initial scan should not be relied upon to exclude significant pancreatic trauma.

Rupture of known abdominal aortic aneurysms: an ethical dilemma.

Elderly patients with abdominal aortic aneurysms (AAA) may be deemed inoperable due to the presence of comorbid conditions. Presentation of these patients with acute rupture can then result in difficult ethical decisions regarding surgical treatment. Over six years, 80 patients were treated emergently for ruptured AAA. Of these patients, 26 (32.5%) had known aneurysms. This study was performed to determine outcome and factors affecting mortality in patients with known AAAs. There were no significant differences between known and unknown AAA groups with regard to operative risk. In the overall group (n = 80), patient delay in seeking treatment averaged 20.4 hours with a trend towards shorter times in those with known AAAs (13.8 hours) compared with the unknown group (23.6 hours; p = 0.09). Medical transport delay, however, was significantly shorter for patients with known AAA (124 minutes versus 230 minutes; p = 0.04). Overall mortality was 56 per cent (n = 45). Those patients with known AAAs had a higher mortality (69%; n = 18) than those with unknown AAAs (50%, n = 27) but this was not statistically significant (P = 0.10). In patients with known AAAs, operative death was related to patient delay, with an average delay in seeking medical advice of 21.3 hours in nonsurvivors compared with 8.6 hours in survivors (P = 0.04). No other risk or demographic factors correlated with mortality. Despite a known AAA, significant delay in seeking medical advice occurred, and this delay resulted in decreased survival. Patient education is imperative if nonoperative treatment is chosen.(ABSTRACT TRUNCATED AT 250 WORDS)