Swiss surgery. Supplement最新文献

The management of patients with coexisting severe carotid and coronary artery disease continues to be controversial. To evaluate the actual risks we have reviewed our experience of 92 patients that underwent simultaneous cardiac surgery and carotid thrombendarterectomy (TEA) over a 10 year period. The mean age was 65 +/- 7 year (41-80), 75% were men. There were 11 REDO cardiac procedures. There were 15 symptomatic and 77 asymptomatic carotid artery stenosis, including 21 with bilateral carotid disease. Mean preop.LVEF was 57.4% (15-80%). Carotid TEA was performed under hypothermia (26 degrees C), preferably with beating heart after an equilibration period of 10 min. The overall mortality was 5.4% (5 patients). 4 of the deaths were reoperative cardiac surgery. Non-fatal myocardial infarction occurred in 1 patient. Postop. neurological complications were diagnosed in 7 patients (8%), 3 transient and 4 permanent neurological deficits occurred. 33 patients had no post-operative complications at all and 25 patients had as only complication, transient arrhythmia. Follow-up revealed a 5-year survival rate of 83% and a cardiac event-free survival of 70%, without neurological events. We therefore conclude that simultaneous carotid TEA and cardiac surgery can be performed using controlled hypothermic cardiopulmonary bypass (26 degrees C), in experienced hands, with an acceptable mortality (5.4%) and low morbidity. Carotid TEA combined with two or more cardiac procedures has the highest mortality and morbidity and should be avoided.

After aortic valve replacement for endocarditis, follow-up treatment with antibiotics is imperative. However, the question of how reliable preoperative and intraoperative diagnosis of endocarditis is in cases involving aortic defects is unclear. Of the 187 patients who underwent aortic valve replacement with or without coronary bypass surgery between June 1992 and June 1994, 150 exhibited no indications of endocarditis during preoperative and intraoperative examinations. In 17 cases (Group A) histological findings indicated acute florid endocarditis in 7 patients and chronic lymphocytic endocarditis in 10. Contrarily, histological examinations of 133 patients (Group B) revealed myxoid and/or sclerotic valve degeneration. WBC and LDH activity, examined one day preoperatively and on the first and second days postoperatively, exhibited no significant differences between the two groups, with the exception of LDH activity on the first postoperative day (Group A: 490 +/- 114, Group B: 403 +/- 132, p = 0.04). Of the clinically asymptomatic patients requiring aortic valve replacement, 11.3% exhibited acute florid endocarditis upon histologic examinations. This subgroup cannot be identified based upon routine preoperative or postoperative laboratory tests or intraoperative observation. Histological examination of the aortic valve is useful for identifying the high percentage of otherwise nonidentifiable endocarditis. Further study will be required to determine therapeutic recommendations based upon such diagnosis.

Between 1962 and 1994 342 patients with transposition of the great arteries (TGA) were treated by atrial correction. Since 1992 the atrial switch operation is the treatment of choice for TGA. We reviewed our 32 year experience. Average age of the patients at operation was 69 months (7 days--8.5 years). 177/342 (52%) patients had a complex TGA: 74 patients with ventricular septal defect (VSD), 49 patients with pulmonary stenosis (PS) and 54 with both (VSD and PS). The 30 day mortality was for the whole series 15.7%. In the last 4 years 7.5%. The actuarial survival rate for all patients was 88% after 10 years and 82% after 20 years. For simple TGA 91% after 10 years and 83% after 20 years, for complex TGA 84% and 81%. The most important cause of death during our longterm observation were heart failure (19 patients) and sudden death (7 patients). Average follow-up for the whole group was 13.4 years. Most of the survivors are functionally symptom free (66% NYHA I) or they have slight symptoms (29% NYHA II). Only 5% were NYHA III or IV. Arterial switch operation has replaced the atrial correction for TGA. Nevertheless the longterm results after atrial correction remains encouraging. The main threat to the patients is the failure of the systemic ventricle.

The use of varicose-ectatically altered veins in bypass surgery is unsatisfactory due to unfavorable flow dynamics and high closure rates. To date surgical repair possibilities to improve the flow profile of autologous vein bypasses have been limited. Using the patient's own veins to produce a biocompound graft, i.e. an ultraflexible hybrid prosthesis, is a simple method by which the surgeon can influence the profile and wall pressure of the bypass. The authors hope thus to improve the patency rate. When forming a biocompound graft, a vein is intraoperatively sheathed inside a fine ultraflexible metal mesh and the two joined with fibrin glue. The mesh hose is pulled over the entire length of the vein with the aid of an application set. Biocompound grafts were used as aorto-coronary bypasses in 9 patients (5 women, 4 men) in whom the possibility of using alternative bypasses did not exist. In 2 patients with femoro-popliteal bypass procedure the autologous varicose-ectatically altered vein was used as a biocompound-graft. Aorto-coronary bypasses: at the time of discharge from the hospital all biocompound bypasses were patent. No perioperative myocardial infarctions were observed. No wound infections occurred. Femoro-popliteal bypasses: at time of discharge from the hospital all biocompound bypasses were patent. The results prove the simplicity and reliability of this method in difficult surgical cases. The biocompound graft offers the surgeon the possibility of using varicose-ectatic veins if alternative bypasses are not available.

In 1989, we reorganized acute and rehabilitation cares for patients operated for non small cell lung cancer (NSCLC) in order to decrease costs by setting up a specialised intermediate care unit (SICU). This report deals with the postoperative complications and the total cost of these cares (SICU, acute and rehabilitation cares) as well as their cost/benefit. From 1990 to 1994, we performed 95 thoracotomies, 7 exploratory and 88 with lung resection (24 pneumonectomies, 8 bilobectomies, 48 lobectomies and 8 segmentectomies or wedge resections). The postoperative staging was I in 52, II in 17, III a in 15, S III b in 2, IV in 2. Patients 30-days postoperative mortality was 2/95 (2.1%). We had in 11 patients respiratory complications (12%; 3 bronchopleural fistulas, 3 pneumonias, 3 pneumothorax > 7 days, 1 empyema, 1 chronic hypoxemia), in 15 patients cardiac arrhythmias which were easily controlled by medication and in 2 general complications (1 hemiplegia, 1 transitory stupor state). The total duration of hospital stay, including SICU, acute and rehabilitative cares, was 32 +/- 10 (3-70) days with a mean total cost of 14,722 Sfr. per case. In conclusion, surgery for NSCLC can be safely performed in intermediate cares without intensive care unit at low costs and with a low morbidity and mortality provided they are staffed by a specialised and well trained team.

The results of surgical procedures for termination of Wolff-Parkinson-White (WPW) Syndrom were assessed in 59 patients undergoing operation between January, 1980 and December, 1993. All cases of WPW were refractory to medical treatment and 14 of 58 patients had one or several syncopes, and 4 of them had to be reanimated. The surgical treatment of these patients was a dissection of an accessory atrioventricular pathway. 15 patients required additional heart operation. A total of 60 accessory pathways were diagnosed preoperatively, 64 were located intraoperatively. The reoperation rate was 3% (2 patients) due to persistent WPW. Incidence of total AV block after the operation was 7% (4 patients). In the late postoperative stage, 12 patients developed supraventricular tachycardias, but none of these cases required a surgical treatment. The actuarial survival rate after 10 years was 100% and after 14 years 96%. We conclude that surgical dissection of accessory pathways offers a good alternative in cases of unsuccessful catheter ablative procedure or in cases of additional heart operation.

The five year patency rate for femoropopliteal vein bypass grafts is around 70% according to the literature. Patency rates for synthetic grafts (eg PTFE, Dacron) range between 43 and 57%. If a vein is not available there is a new polyurethane 6 mm artery substitute on the market, that has shown in vitro promising physical characteristics and good long term results after implantation in dogs. In a prospective, randomized trial the results of the new polyurethane graft (PUR) were compared with those of a Dacron graft of the same diameter. Included in the study were 20 patients with lower limb ischemia stage Fontaine II B, III and IV, 10 in each group. Patency rates, handling of the graft and complications were analysed. During the one year follow up 7 PUR grafts had to be changed due to recurrent bypass occlusion within the first 3 months. At the end of the year there were only one PUR-bypass but 8 Dacron grafts open. 5 PUR grafts were examined histologically and no morphological reason for the occlusion, especially no myointimal hyperplasia, was found. A special regard was brought to the arterial run-off in both groups. It was confirmed to be comparable with only slightly better data for the PUR group. The exact reasons for the astonishing bad results of the PUR graft for femoropopliteal above knee bypass cannot be explained in our study. Due to the unexpected high occlusion rate the study was stopped earlier then planned.

In the present study the thromboresistance of heparin-coated diffusion membrane oxygenators (Jostra, M 30) combined with heparin-coated venous reservoirs, tubing sets and arterial filters was investigated in six bovine experiments (70 +/- 5 kg). The perfusion with reduced systemic heparin dose (100 IE/kg) body weight) was performed with activated clotting time over 180 seconds. The perfusion began with a blood flow of 31/min and was maintained during six hours. Clotting studies including blood platelet count, activated clotting time, fibrinogen (factor I), antithrombin III and fibrinopeptid A were performed before the operation and ten minutes, two hours and five and six hours after beginning of bypass. The venous and arterial saturation remained stable during the whole investigation. After ten minutes activated clotting time dropped from 619 +/- 114s to 203 +/- 15s after six hours (p < 0.05). The antithrombin III level changed significantly from 109 +/- 11% to 95 +/- 16%. Factor 1 and fibrinopeptid A changes were not significant: from 1.6 +/- 0.3 g/1 to 1.5 +/- 0.3 g/1, and 3.0 +/- 1.4 ng/mL to 3.5 +/- 1.2 ng/mL, accordingly. There were no mechanical defects and especially no plasma leakage. Slight sediments were found only in areas of stagnant blood flow. The investigated bypass circuit with reduced systemic heparinization seems therefore particularly appropriate for long-term perfusions.