Treatment of severe peptic esophageal stricture with Roux-en-Y partial gastrectomy, vagotomy, and endoscopic dilation. A follow-up study.

Eleven patients with dysphagia caused by severe esophageal stricture (length 2 to 10 cm) resulting from reflux esophagitis were treated with fibroendoscopic dilation (Eder-Puestow) and Roux-en-Y partial gastrectomy with vagotomy during 10 years (1979 to 1988). There was no operative mortality, but complications developed in three patients: One patient had a mediastinal abscess demanding thoracotomy as a result of esophageal perforation after dilatation; one had postoperative pneumonia; and one patient had ileus. After a mean follow-up of 4 years (range 1 to 10 years) esophagitis healed in all cases, as judged by endoscopy. Eight patients were asymptomatic, but three had slight transient dysphagia. Postoperatively one to eight dilations (average three to four) were needed to relieve dysphagia in the first postoperative year, but later the stricture healed in every case. Postoperative pH measurement was performed in six latest patients and showed complete absence of reflux in all cases. It is concluded that Roux-en-Y partial gastrectomy with vagotomy and endoscopic dilation is an effective, simple, and safe procedure in the management of severe peptic esophageal (acid or alkaline esophagitis) stricture. However, occasional postoperative dilations at the outpatient clinic are often needed in severe cases in the first postoperative year.

Dilatation of ascending aorta in patients with repaired coarctation.

The long-term outcome following repair of typical aortic coarctation in adulthood may be complicated by disorders of the ascending aorta. Follow-up averaging 15 years revealed a 3.8% incidence of dilatation of the ascending aorta after such late repair. Hypertension and concomitant aortic valvular disease were common in these patients. Aortic dilatation can appear years after coarctation repair, irrespective of the operative technique and its success, and can lead to death from aortic dissection or rupture of an aortic aneurysm. Careful follow-up after coarctation repair in adulthood is advisable to detect late aortic complications.

Morphological and histopathological aspects of aneurysms after patch aortoplasty for coarctation.

Repair of coarctation of the aorta by synthetic patch grafting has been complicated by late aneurysm formation. These aneurysms differ macroscopically from atherosclerotic thoracic aortic dilatations. Specimens for microscopic examination were taken from 14 of 20 patients undergoing aneurysm resection. Histological analysis of the specimens showed medionecrosis in 13 patients of the specimens showed medionecrosis in 13 patients (93%), foreign body reaction in 11 patients (78%), and intimal thickening in 3 patients (21%). The three layers of the aortic wall could be identified in the aneurysms. On the basis of these results, we discuss the etiologic factors and pathogenetic mechanisms involved in the development of these aneurysms.

Effect of antiplatelet and anticoagulant therapy on patency of femorotibial bypass grafts.

In a retrospective study, 210 autogenous femorotibial saphenous vein grafts inserted during the 15 years from 1967 to 1982 were followed-up for a mean period of 62.3 +/- 5.7 months. Seven patients, who had had eight grafts died in hospital. The remaining 202 grafts fell into three groups: (1) Sixty grafts in patients who received 325 mg of dipyridamole and 1.0 g of acetylsalicylic acid daily, starting on the second postoperative day and continuing for six months. (2) One hundred and two grafts in patients on no antithrombotic therapy. (3) Forty grafts in patients on warfarin therapy to maintain the prothrombin time (prothrombin-proconvertin method) within the therapeutic range (0.10 to 0.20). Medication was continued for six months. This group included more high-risk patients than the other two groups. The mean ages and the incidence of risk factors did not vary significantly between the groups. The patency rates in three groups at five years were 62.5%, 44.0% and 26.0% and at ten years 48.5%, 25.0% and 21.5% for the dipyridamole and acetylsalicylic acid, no therapy and warfarin groups, respectively. The limb salvage rates were 100%, 96% and 85% in the dipyridamole and acetylsalicylic acid, no therapy and warfarin groups respectively. Thus, the best results were seen in the aspirin/dipyridamole group.

Hematuria is an indication of rupture of an abdominal aortic aneurysm into the vena cava.

During a period of 13 years 11 patients were operated on because of a spontaneous aortocaval fistula caused by a ruptured abdominal aortic aneurysm. The classic diagnostic signs of an aortocaval fistula (pulsatile abdominal mass with bruit and high output heart failure) were present in approximately half of the patients, whereas hematuria was a constant finding in all patients. Six patients had macrohematuria, and five had microhematuria. Seven patients (64% survived, and four had postoperative complications: 1 ileus, 2 postoperative pneumonias, 2 deep venous thrombosis, 1 postoperative hemorrhage. The mean operative blood loss was 7 L. After operation the average follow-up time was 4 years. In four patients who died the perioperative (within 30 days) causes of death were renal failure, a bleeding duodenal carcinoma, myocardial infarction, and operative bleeding. It is concluded that hematuria is a more frequent finding than earlier assumed among patients whose abdominal aortic aneurysm has ruptured into the vena cava. The presence of hematuria in a patient suffering from an abdominal aortic aneurysm is an indication for aortography to rule out an aortocaval fistula.

Long-term results of direct aortoplasty for repair of aortic coarctation in adults.

The long-term results of 14 adult patients who underwent a direct aortoplasty for aortic coarctation were reviewed. The mean age of the patients at operation was 31.5 years. Three of the patients died; 1 died perioperatively, and 2 died later of cardiovascular disease. The survivors were followed for 15.8 years. None of the patients had complications at the site of coarctation repair. This contrasts with our earlier findings on patch graft aortoplasties, which showed a high incidence of postoperative aneurysm at the repair site. The etiology of these aneurysms is discussed with reference to the information provided by the present study.

Diagnosis and treatment of subclavian artery aneurysms.

The diagnostic features and operative results in 13 patients with subclavian artery aneurysms were analysed. Symptoms related to subclavian artery aneurysms were present in seven patients, whereas six patients were asymptomatic and the aneurysm was discovered incidentally on chest X-ray. Angiography was the most valuable diagnostic examination and was also necessary in planning the operation. A correct preoperative diagnosis was made in five of six patients with computed tomography. Resection of the aneurysm was performed in nine and aneurysmal exclusion in the latest four patients. Direct reconstruction was used in nine and in four cases an extra-anatomic carotico-subclavian bypass was performed. Postoperative complications arose in two symptomatic and in four asymptomatic patients (46%: two strokes, two wound infections demanding extirpation of the prosthesis in one patient, two pareses of the recurrent nerve and one postoperative haemorrhage). Operative mortality was one patient. Follow-up data was available for all patients for periods of 6 months to 14 years. The vascular graft was patent in all patients. The authors conclude that subclavian artery aneurysm must be included in the differential diagnosis of all obscure upper mediastinal masses as seen on the chest X-ray and examined with CT and angiography. Exclusion of the aneurysm with extra-anatomical reconstruction is technically easier and gives the same postoperative long-term results as resection of the aneurysm and direct reconstruction. A relatively high complication rate after operation on asymptomatic subclavian aneurysms indicates a need for re-evaluation of operative indications in asymptomatic patients.

Pseudoaneurysm of the left ventricle following mitral valve replacement. Report of two cases and review of the literature.

Two cases of left ventricular (LV) pseudoaneurysm following mitral valve replacement (MVR) are presented. In one patient the false aneurysm developed after an initially successful correction of intraoperative left ventricular wall rupture while the other case resulted from an apparently uncomplicated MVR performed because of staphylococcal endocarditis. Both cases were detected by combined 2-dimensional and Doppler echocardiography. The operative treatment was similar in both patients. After extirpation of the old prosthesis, the orifice of the pseudoaneurysm was closed from inside the heart, either with a Dacron patch or using interrupted sutures supported by a teflon pledget. One of the patients died one month postoperatively but the other one recovered and is clinically well 6 months after repair. She has, however, a residual communication between the LV and the pseudoaneurysm.

Use of omental pedicle for treatment of Buerger's disease affecting the upper extremities. A modified technique.

We present a report of a 58-year-old male patient who suffered from Buerger's disease of the upper extremities verified by microscopy and angiography. Despite medical treatment and repeated thoracic sympathectomy he developed gangrene at the tip of his right thumb and index finger. Pedicled omentum was prepared through midline laparatomy, placed through subcostal incision to the subcutaneous space of the forearm and affected fingers. Rest pain disappeared by the fifth day after surgery. The omental pedicle was ligated six weeks post-operatively and the extremity mobilized. The thumb healed well. The index finger required amputation because of continuing infection. Five years postoperatively the patient has a good functioning hand in which the transferred omentum has retained its viability.

Polydioxanone in coronary vascular surgery.

We have used polydioxanone (PDS) in 50 patients who underwent coronary artery bypass grafting. The anastomoses consisted of suturing an autologous vein graft to the coronary artery (122 operations), a vein graft to the aorta (63 operations) and the internal mammary artery to the coronary artery (33 operations). The recipient coronary artery was subjected to endarterectomy in 28 instances. The anastomoses proved to be reliable in the early postsurgical period; no bleeding was attributed to the PDS suture. Clinical follow-up for a maximum of two-and-half years, completed using control coronary angiograms in selected cases, demonstrated good results. The practical properties of PDS were evaluated to be at least as good as those of polypropylene. Experiments have clearly shown that small artery anastomoses heal more favourably after the use of absorbable sutures than after the use of nonabsorbable sutures. Because of this finding and on the basis of our clinical experience, we believe the application of PDS in coronary surgery should be recommended as an alternative treatment.

Aneurysms after patch graft aortoplasty for coarctation of the aorta: long-term results of surgical management.

Twenty-two (32.8%) of 67 patients who had patch graft aortoplasty for aortic coarctation underwent reoperation because of aneurysm formation opposite or at the site of the patch. The mean age at primary repair was 25.3 years (standard deviation, 9.5 years). Reoperation took place 12.3 years (standard deviation, 3.7 years) later. In 19 patients, the aneurysm was resected and the aorta reconstructed with a tubular prosthesis. In 3 patients, the aneurysm was given external support. There were no hospital deaths. Recurrent nerve paralysis (36%) and bleeding necessitating repeat thoracotomy (32%) were the most common complications. Mean follow-up was 4.6 years. No aneurysms developed at the site of reoperation. Two patients died of causes not related to reoperation. Reconstruction with a tubular prosthesis gives good long-term results in patients with aneurysm formation after patch grafting for coarctation. External support offers technical advantages in select patients. Close follow-up of patients who have coarctation repair with a patch graft is essential.

Femorotibial bypass grafting for lower limb ischaemia.

The results of 305 femorotibial bypass grafts performed in 246 patients are presented. Of these operations 246 were primary and 58 secondary or tertiary. A total of 66 diabetic patients were in the series. An autogenous saphenous vein graft was employed in 196 primary operations, the other grafts used being PTFE, human umbilical cord vein graft, venous allograft and knitted dacron velour graft. Hospital mortality was 8 patients (2.6%), while late mortality was 73 patients, 39 of them having had patent grafts. There were 89 (29.2%) immediate or early hospital failures. Two-hundred-sixteen grafts were followed for a mean observation time of 62.3 +/- 5.7 months. The cumulative patencies were analyzed using the life-table method. One, five, and ten year overall patencies for saphenous vein grafts as indicated by claudication were 73%, 53% and 35%, respectively. In rest pain, the patency rates were 62%, 46% and 40% at similar intervals. In impending gangrene the patencies were 43%, 35% and 20%, respectively. The patencies for arterial substitutes were generally poor, i.e., 35% and 15% at one and five years. None of the graft substitutes were followed for up to ten years. Diabetic patients had a significantly lower patency rate than nondiabetics (p = 0.002). The impact was remarkable if impending gangrene co-existed. In all these situations the early graft failure ensued. Both the run-off and inflow status affected the patency rates. This was significantly lower (p = 0.001) when only one distal branch was visualized in angiography.

One-stage vascular surgery for abdominal aortic aneurysm infected by salmonella.

A case is presented of abdominal aortic aneurysm infected with salmonella enteritidis, maintaining septicaemia. Immediate surgery became necessary because of imminent rupture of the aneurysm. The infected thrombus within the aneurysmal sac was debrided, with irrigation of antibiotic solution, and in situ aorto-iliac reconstruction was carried out. A prolonged course of ciprofloxacine and a short course of vancomycin were administered. Recovery was uneventful. The infection parameters are normal 6 months postoperatively and CT-scan shows no signs of periprosthetic infection. The relevant literature concerning the surgical procedures for mycotic aneurysms is reviewed.

Primary tumours of the sternum.

In 1966-1986, two men and four women (mean age 47.5 years) underwent surgery for primary sternal tumour. Three of the tumours were benign (two condromata, one osteochondroma) and three were malignant (two chrondrosarcomata, one reticulum cell sarcoma). Inflammatory or degenerative lesions impeded differential diagnosis in three additional cases (without tumour). The tumours were treated with radical resection of the affected part of the sternum, including the relevant attached structures. Marlex-mesh reconstruction of the defect was necessary in four cases. There was no operative mortality. One Marlex graft became infected. At follow-up (average 11.1 years, range 9.0-14.7 years), five patients were alive without recurrence of tumour and the sixth had died of unrelated cause.

Femoral-tibial bypass for limb salvage.

From 1967 to 1982, 305 femoral tibial bypasses were performed. Of these 180 (59%) were performed on limb salvage indication. A reversed autogenous saphenous vein was used in 134 instances, among 46 vein substitutes there were 15 vein allografts, 13 human umbilical cord vein grafts, 12 PTFE grafts and six dacron grafts. Hospital mortality was six patients. An additional 37 patients died during the follow-up period. The patency rates for saphenous vein bypass grafts were 62.5%, 48%, and 25% at one, five, and ten years, respectively, and 33% and 25% at one and five years, respectively, for the vascular substitutes. The mean +/- SD follow-up time was 62.27 +/- 5.7 months. During the early postoperative period 23 legs (12.7%) had to be amputated. During the follow-up period an additional 14 legs (7.8%) were lost giving a limb salvage rate of 79.5%.

Management of vascular complications in thoracic outlet syndrome.

Arterial complications of thoracic outlet syndrome (TOS) were surgically treated in 11 patients (12 limbs) and venous complications in five (6 limbs). Arteriography showed total occlusion or significant stenosis of the subclavian artery in eight patients (bilateral in 1), with complicating peripheral thrombosis in three. Two patients had unilateral subclavian artery aneurysm: One was the patient with bilateral subclavian occlusion, and the other also had brachial artery embolism. Yet another patient had brachial thrombosis. Treatment included reconstructive surgery (3 limbs), thoracic sympathectomy (3) or decompression alone (6). Of the five patients with venous TOS complications, four were found at phlebography to have subclavian thrombosis and one had significant bilateral subclavian obstruction. Treatment was transaxillary first-rib resection (4 cases) or division of soft-tissue bands and hypertrophied anterior scalene muscle (1 case). After follow-up averaging 9 years, eight of the nine survivors in the arterial group were working and seven were asymptomatic. All five in the venous group were working and only two had slight, strain-related symptoms. Impaired arterial flow in TOS can usually be managed with decompression, but direct surgery (bypass or thrombectomy) or thoracic sympathectomy is required in cases with severe ischemia with proximal occlusion and after resection of a subclavian aneurysm or in cases with unilateral Raynaud's phenomenon or thrombosis of small arteries. For venous symptoms decompression alone suffices.

Primary tumours of the ribs.

Thirty-four primary rib tumours (24 benign, 10 malignant) were surgically treated in 1966-1985. The mean age was higher and the tumour diameter was greater in the patients with malignant, than in those with benign neoplasm. The benign tumours were excised without operative death. At follow-up after a mean of 12.3 years there was no recurrence of benign growth, but in two cases with initial diagnosis of chondroma a regrowth at the same site proved to be chondrosarcoma. Among the cases of malignant tumour there was one operative death from pulmonary embolism, after radical resection of sarcoma. None of the four patients with chondrosarcoma had recurrence 6-13 years after surgery. There was no long-term survival among the patients with other forms of sarcoma or malignant tumour of the reticuloendothelial system.

Congenital esophageal cysts in adults.

Sixteen adult patients with congenital esophageal cysts were operated on between 1957 and 1979. Preoperatively, 7 patients (44%) were asymptomatic and the cyst was found incidentally on a routine chest roentgenogram. Esophageal symptoms were present in only 3 patients (19%), whereas most symptomatic patients had precordial sensations or arrhythmias. A correct preoperative diagnosis was made in only 1 patient. After enucleation of the cyst, preoperative symptoms were alleviated in all patients and short-term results were excellent. However, long-term follow-up 13.2 +/- 5.6 (+/- standard deviation) years later revealed moderate reflux in 9 (64%) of the surviving 14 patients. During esophagoscopy, macroscopic esophagitis was found in 12 (92%) of 13 patients. On histological examination of specimens obtained by forceps biopsy, esophagitis was present in 10 (77%) of 13 patients and included Barrett esophagus in 2. We conclude that, despite excellent early results, long-term follow-up of patients who undergo operation for congenital esophageal cysts is indicated because of the increased incidence of reflux esophagitis.

Smooth muscle tumours of the oesophagus.

Twelve patients with oesophageal smooth muscle tumour were operated on between 1955 and 1984 in the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital. Eleven tumours were leiomyomata, the twelfth was a leiomyosarcoma. Dysphagia (83%) and chest or epigastric pains (67%) were the most common symptoms presented. All patients underwent transthoracic removal of the tumour. Complications of the surgery included two cases of postoperative oesophageal fistula; in both instances the lumen of the oesophagus had been entered during the extirpation of the tumour. The surgery was effective in eliminating the most prominent symptom, i.e. dysphagia. However, follow-up examinations 11.1 +/- 6.8 (SD) years later revealed reflux symptoms and endoscopically and histologically verified oesophagitis in seven of the nine (78%) surviving patients. Additionally, two of them had developed Barrett's oesophagus, 10 and 19 years, respectively, after the primary surgery. These two patients underwent subsequent transabdominal antireflux procedures (Nissen fundoplication). We conclude that long-term follow-up of patients who have been treated for benign oesophageal tumour is indicated.