Completion pneumonectomy: analysis of operative mortality and survival

BACKGROUND: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome. METHODS: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period. RESULTS: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease. CONCLUSIONS: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.     

Heterogeneity of immunoglobulin G response to Helicobacter pylori measured by the unweighted pair group method with averages

OBJECTIVE: The 30-day operative mortality for thoracotomy in lung cancer is described herein. METHODS: From January 1994 through December 1994, the Japanese Association for Chest Surgery surveyed the number of thoracotomies for lung cancer by operative procedure, age, and operative mortality. The operative mortality was defined as death within 30 days of operation. RESULTS: The total number of operations was 7099. The overall 30-day operative mortality was 1.3%. By operative procedure, the mortalities were 3.2% for pneumonectomy, 1.2% for lobectomy, and 0.8% for a lesser operation, which showed a significant difference between pneumonectomy and lobectomy (p < 0.01). The mortality by age was 0.4% for patients younger than 60 years, 1.3% for those aged 60 to 69, 2.0% for those aged 70 to 79, and 2.2% for those aged 80 or older, which showed significant differences between the less than 60-year and 60- to 69-year-old groups, and between the 60- and 69-year-old and 70- and 79-year-old groups (p < 0.01 and p = 0.047, respectively). Pneumonia and respiratory failure caused most deaths (51.6%). CONCLUSIONS: The operative mortality in Japan for thoracotomy in lung cancer was satisfactorily low. The results of this study on a large population could serve as a standard when discussing the operative outcome of lung cancer.     

Operative risks of major hepatic resections

BACKGROUND/AIMS: Despite recent advances in liver surgery, major hepatic resection still remains a major operation with significant mortality and morbidity. We report our experience with major hepatic resections with particular regard to the operative risk of this procedure in cirrhotic and non-cirrhotic patients. METHODOLOGY: One hundred and ninety-three patients with malignant (77.2%) or benign (22.8%) liver tumors underwent major hepatic resection between January 1981 and December 1995. Twenty-eight patients had cirrhosis. We performed 109 right hepatectomies (56.5%), 30 right extended hepatectomies (15.5%), 32 left hepatectomies (16.6%), 15 left extended hepatectomies (7.8%) and 7 trisegmentectomies (3.6%). In 63 patients (32.6%), single or multiple associated resections were performed. Selected intraoperative and outcome data were compared in this retrospective analysis. RESULTS: There were 9 intraoperative complications: 4 injuries of the contralateral biliary duct, 4 injuries of the vena cava and 1 partial stricture of the left hepatic vein. The mean operation time was 284 +/- 97.9 min. The mean number of transfused units of blood was 1.6 +/- 1.8. The patients with operative complications required a median of 5 units of blood (range: 1-11) (p = 0.001). The intra- and postoperative mortality was 3.1%. Seventy-six patients (39.3%) developed postoperative complications, and 20.7% of these were major complications. Blood replacement was significantly higher in the cirrhotic patients (p = 0.007). No other significant differences were found between the cirrhotic and non-cirrhotic patients. CONCLUSIONS: Major hepatic resection for malignant or benign disease can be performed safely with minimal morbidity and mortality in patients with normal livers and in selected cirrhotic patients classified as Pugh A.     

Complications of laparoscopic cholecystectomy in China: an analysis of 39,238 cases

OBJECTIVE: To investigate the complications of laparoscopic cholecystectomy in China. METHODS: All Chinese articles about laparoscopic cholecystectomy published between April 1994 and November 1995 were identified through CMCC (Chinese Medical Computerized Contents). From more than 600 titles, 105 articles were screened for analysis. Another 21 articles from the 6th Biliary Surgical Congress and 300 cases from the General Hospital of PLA were added. A total of 39,238 cases of laparoscopic cholecystectomy from 91 hospitals were studied. RESULTS: Severe complications of laparoscopic cholecystectomy were identified in 409 (1.04%) patients, including bile duct injury (in 0.32% of patients), postoperative cystic duct leak (0.11%), postoperative bile leak (0.20%), peritoneal abscess (0.07%), bowel injury (0.06%) and postoperative hemorrhage (0.1%). Fourteen postoperative deaths (0.04%) resulted from operative injury. CONCLUSIONS: The data demonstrate that laparoscopic cholecystectomy is an operation associated with low morbidity and mortality rate, but bile duct injury is still a major problem. Complications of laparoscopic cholecystectomy can be minimized by improving operative procedure.     

Operative results after the Cox/maze procedure combined with a mitral valve operation

BACKGROUND: There have been few reports on postoperative morbidity and mortality analyses after concomitant mitral valve operation and the Cox/maze procedure. METHODS: Between April 1993 and August 1995, 87 consecutive patients with chronic atrial fibrillation underwent a mitral valve operation and concomitant Cox/maze procedure at Iwate Medical University. The patients were divided into the replacement group (n = 31) and repair group (n = 56) according to the method of mitral valve replacement. Our initial experience with the combined operative procedures is presented along with the operative mortality and morbidity rates. Univariate analysis on preoperative and intraoperative variables affecting early mortality and morbidity is carried out retrospectively. RESULTS: Total cardiopulmonary bypass time in all patients was 177.2 +/- 70.1 minutes. Total aortic cross-clamp time was 121.7 +/- 30.8 minutes. Total intensive care unit stay was 5.3 +/- 7.9 days. The average intubation period was 55.5 +/- 187.6 hours. The intensive care unit stay and the intubation period of the replacement group were longer than those of the repair group. There were four operative deaths among the 87 patients (4.6%). All repair group patients survived operation, whereas 4 replacement group patients died after operation. In all patients, the New York Heart Association functional class was higher (p = 0.028) in those who died than in those who survived. The overall restoration rate from atrial fibrillation was 79.5% (66 of 83 survivors). Seventeen patients (20.5%) had persistent atrial fibrillation postoperatively. Sick sinus syndrome occurred in 7 patients (8.4%). In the repair group, the restoration rate was 76.8%, whereas in the replacement group it was 85.2% for the survivors. CONCLUSIONS: The Cox/maze procedure can be combined with a mitral valve operation with acceptably low operative risk. Analysis of risk factors of early mortality revealed that the type of mitral valve operation (replacement versus repair) and higher preoperative New York Heart Association functional class were associated with mortality. Long-term results from this combined procedure should be clearly demonstrated before its universal acceptance.     

Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma

BACKGROUND: After pneumonectomy for bronchogenic carcinoma, the residual lung may be the site of a new lung cancer or metastatic spread. METHODS: From 1989 to 1995, 13 patients with carcinoma on the residual lung after pneumonectomy for lung cancer were operated on. Three segmentectomies and 7 simple wedge resections were performed, 2 patients had multiple wedge resections, and 1 patient had an exploratory thoracotomy. Nine patients had a primary metachronous bronchogenic carcinoma, 3 had metastases from bronchogenic carcinoma, and no definite conclusion was reached in 1 case. RESULTS: No postoperative mortality was observed. Four patients had postoperative complications. The mean postoperative hospital stay was 14 days. Seven patients are alive, including 5 patients without evidence of disease. Six patients died of their disease, all with pulmonary recurrences. The overall median survival was 19 months, with a probability of survival at 3 years (Kaplan-Meier) of 46% (95% confidence interval, 22% to 73%). CONCLUSIONS: Limited pulmonary resection for lung cancer after pneumonectomy for bronchogenic carcinoma is feasible with very low morbidity. In highly selected patients, surgical resection might prolong survival.     

Primary endoprosthetic replacement for acute femoral neck fractures. A review of 150 cases

A review of 150 consecutive endoprosthetic replacements for acute displaced femoral neck fractures was undertaken to investigate the following serious criticisms of the method. The first is excessive hospital mortality and morbidity, especially in comparison to internal fixation procedures retaining the femoral head. The second is pain, derived from the "unphysiologic" nature of placing a metal prosthesis against otherwise normal acetabular cartilage. In the first instance the procedure is condemned as too major an operative procedure, poorly tolerated by elderly patients. In the second, it is a poor procedure if it requires revision in a patient incapable of withstanding more than one operation. A detailed follow-up shows that the in-hospital mortality in patients averaging 79.8 years of age, was 4%, lower than published mortality for either hemiarthroplasty or internal fixation. Close postoperative monitoring, antibiotic and antiembolic prophylaxis (2.0% infection, 6% embolic complications), and rapid mobilization contributed significantly to the increased survival. Painful endoprostheses, the most frequent complication, occurred in 16.7% of the 125 patients available for follow up at an average of 21 months. The causes of pain were considered technical problems judging prosthetic neck length, head size, sinking and loosening. Dissolution of the medial femoral neck was associated with a narrow stem prosthesis in five of six of these failures. The above statistics suggest that primary endoprosthetic replacement for displaced femoral neck fractures carries with it neither the excessive mortality and morbidity nor the pain induced potential for early reoperations that have been suggested by the recent literature.     

Twenty-three years of experience with sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi

A 23 year experience with papillotomy, sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi shows sphincteroplasty to be the best procedure, with 79% of the patients obtaining a good result. The procedure was done for a demonstrable organic change in the sphincter, often associated with acute cholecystitis in older patients, the postcholecystectomy syndrome in those in whom a long cystic stump had been left at the first operation or in patients with chronic recurring pancreatitis. The study included 138 private patients observed from two months to 22 years. There were four postoperative deaths, an operative mortality of 2.9%, as two patients had been operated upon twice. The poor results were associated with recurring attacks of pancreatitis not cured by the procedure or developing subsequent to it, probably being attributable to persistent obstruction of the terminal part of the pancreatic duct. The results suggest that sphincteroplasty, if performed on suitably selected patients, is a safe procedure which should give good results in more than 75% of the patients.     

Mammalian glial cells in culture synthesize acetylcholine

OBJECTIVE: To evaluate the postoperative outcome and long-term results of patients who underwent iterative and extended pulmonary resection leading to completion pneumonectomy for pulmonary metastases. METHODS: From January 1985 to December 1995, 12 patients (mean age 45 years) underwent completion pneumonectomy for pulmonary metastases. These patients represent 1.5% of all pulmonary metastases operated on. There were 5 sarcoma and 7 carcinoma patients. Before completion pneumonectomy, 8 patients had only one pulmonary resection (wedge resection, 2; segmentectomy, 2; lobectomy, 4), 3 patients had two operations and finally, 1 patient had multiple bilateral wedge resections and 1 lobectomy. The median interval time between the last pulmonary resection and completion pneumonectomy was 13.5 months (range 1-24 months). RESULTS: There were 10 left and two right completion pneumonectomies. Three patients had an extended resection (1 carina; 1 chest wall; 1 pleuropneumonectomy). Intrapericardial dissection was used in 3 patients. Two patients died within 30 days of the operation: 1 died of postoperative complications (8.3%) whereas the other died of rapidly evolving metastatic disease. The remaining 10 patients had an uneventful postoperative course. Only 1 patient is still alive and free of disease 69 months after completion pneumonectomy. One patient is alive with disease, another was lost to follow-up; 9 patients died of metastatic disease. The median survival time after completion pneumonectomy was 6 months (range 0-69 months). The estimated 5-year probability of survival was 10% (95% CI: 2-40%). CONCLUSIONS: Indications for both iterative and extended pulmonary resection for PM may be discussed only in highly young selected patients; the extremely poor outcome of our subgroup of patients should lead to even more restrictive indications of CP for pulmonary metastatic disease.     

Characterization of two Chinese hamster ovary cell lines expressing the COOH-terminal domains of sterol regulatory element-binding protein (SREBP)-1

BACKGROUND: To assess surgical outcome after oesophagectomy, we reviewed operative techniques and postoperative course among 90 patients who underwent oesophageal resection for malignancies from January 1989 to December 1995. METHODS: There were 73 males and 17 females; mean age was 64.2 years. Indications were squamous cell carcinoma in 49 patients and adenocarcinoma in 41. Preoperatively 7 patients had chemotherapy and 18 benefited from radiochemotherapy. There were 56 total thoracic oesophagectomies, with anastomosis in the neck in 34 patients and at the thoracic inlet in 22. In 34 cases operation was limited to distal oesophageal resections. Digestive continuity was restored with the stomach in 62 patients, with the colon in 24, and with a jejunal loop in 4. A feeding jejunostomy was constructed in 48 patients with a gastric transplant. RESULTS: Mortality was 10% (9 patients), decreasing from 18.5% (before 1993) to 3.8% (since 1993). One patient died in the colonic graft group and 8 in the gastric pull-up group. Postoperative complications occurred in 9 patients after colonic interposition and in 23 after gastric pull-up; they consisted in pulmonary infection or insufficiency in 26 patients, cerebrovascular accident in one, renal insufficiency in 2, recurrent nerve palsy in 4, and anastomotic leakage in 6. Transhiatal approach was not associated with a decreased incidence of postoperative deaths or complications. Eighteen patients (72%) developed postoperative pulmonary complications after preoperative chemotherapy. CONCLUSION: Oesophagectomy can be performed with low mortality. A colonic graft is not associated with an increased incidence of perioperative deaths or complications and is the substitute of choice when there is any question regarding gastric vascularization, or in young patients with long life expectancy. Preoperative neoadjuvant treatment significantly increases postoperative pulmonary complications.     

Treatment of tumors of the pancreatic head with suspected but unproved malignancy: is a nihilistic approach justified?

A critical analysis of morbidity and mortality for pancreatico-duodenectomy was performed on 221 patients. During the 1960s and 1970s, the morbidity and mortality for pancreaticoduodenectomy were so high that many thought the operative procedure ought to be abandoned. During the 1980s, however, many centers reported mortality rates around 5% and a morbidity of 25% to 35%. Others still reported a mortality of more than 10% and a morbidity of up to 65%. The reasons for these discrepancies are of major interest. In a prospective case-control study 760 patients with malignant and benign diseases of the pancreas were treated in our hospital between September 1, 1985 and April 30, 1997. In 221 cases (128 men, 93 women; mean age 61 years, range 23-83 years) a partial (n = 209) or total (n = 12) pancreaticoduodenectomy, in 12 cases combined with portal vein resection, was performed. Surgical complications were seen in 25%, but less than half of them were severe. General complications were seen in 18.5%. The 30- and 90-day mortality rates were 3.1%, and 5.7%, respectively. In a regression analysis the intraoperative blood loss, preoperative serum bilirubin, diameter of the pancreatic duct, and occurrence of surgical and nonsurgical complications had an independent influence on mortality. In addition to the experience of the surgeon in selecting the patients and his or her personal technical skills when performing a pancreaticoduodenectomy, better anticipation and management of postoperative complications is essential for improving the results of this operation.     

Laparoscopic cholecystectomy--analysis of the first 100 operations

Laparoscopic cholecystectomy is a surgical method of removing the gallbladder through four small incisions on the abdominal wall using laparoscopic technique with specially designed equipment and instruments. The method is characterized with the following: reduced operative trauma and postoperative pain, shorter hospital stay, quicker recovery and better cosmetic effect. This method is in surgical practice in the last 10 years, whereas in General Hospital in Senta, in the surgical department it was introduced in June 1995. In the period June 16, 1995-March 1, 1996 one hundred patients underwent laparoscopic cholecystectomy. The median age of patients was 48 years; 79% were females and 21% were males. There was no operative mortality. Four (4%) mild complications occurred. Conversion was performed in only one patient (1%). The average operation time was 54 minutes, while the postoperative hospital stay was 2.3 days.     

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair

OBJECTIVE: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. SUMMARY BACKGROUND DATA: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. METHODS: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. RESULTS: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. CONCLUSIONS: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.     

Carinal resection for primary lung cancer--with special attention to a modified double-barrel method

Carinal resection for primary lung cancer was clinically evaluated. Carinal resection was performed in 18 patients, 17 males and one female, with a mean age of 64 years. Nine patients underwent carinal reconstruction and the other 9 sleeve or wedge pneumonectomy. The carinal reconstruction was of the montage type in one patient, the one-stoma type in 2, and the modified double-barrel method in 6. The modified double-barrel method is a technique that we developed by adding bronchial end-to-side anastomosis to the tracheobronchial end-to-end anastomotic site. A pedicled intercostal muscle flap was used for covering the anastomotic site. The postoperative respiratory complications after carinal reconstruction were anastomosis failure in 4 patients (pin-hole in 3) and respiratory failure in 2. However, no anastomosis stricture occurred, and recovery was satisfactory. There were no respiratory complications after pneumonectomy. One patient had renal failure before surgery and died of multiple organ failure 23 days after a montage type carinal reconstruction. The other 17 patients did well and could be discharged from the hospital and the overall mortality rate was 5.6%. No anastomosis stricture occurred in the modified double-barrel method. By carinal reconstruction covering of the anastomotic site is mandatory to prevent fatal postoperative complications.     

Complications of abdominal right-thoracic (Ivor Lewis) esophagectomy

Esophageal resection and reconstruction are associated with significant operative and postoperative morbidity and mortality. Careful evaluation of the patient's cardiopulmonary status; proper preparation of the patient with smoking cessation, exercise, and cardiopulmonary rehabilitation; assessment of the stage of disease; selection of a suitable operative technique; and meticulous attention to technical details help reduce the incidence of complications and ensure a successful outcome in this technically challenging procedure.     

Sleeve pulmonary arterial resection for bronchogenic carcinoma

Two cases of bronchogenic carcinoma undergone left upper lobectomy (R 3) with bronchoplasty and sleeve pulmonary arterial resection via mid-sternotomy were reported. Both cases were squamous cell carcinoma originated in the orifice of the left upper lobe. Case 1 was stage IIIB (T2N3M0) bronchogenic carcinoma, its postoperative course was uneventful and died of distant lymphatic metastasis thirty-three months after operation. Case 2 was stage II (T2N1M0) bronchogenic carcinoma and its postoperative management was laborious because of hard expectoration of the sputum but is doing well fifteen months after operation. In order to preserve adequate pulmonary function and to maintain reasonable quality of life (QOL) for the patients with impaired pulmonary function, this angioplastic procedure seems to be acceptable. It is still under discussion to perform this procedure for the patients who would be able to withstand undergoing pneumonectomy, therefore we adopt this method only for every patient for whom it is difficult to maintain desirable QOL after pneumonectomy. Namely, for the patient whose predicted one second forced expiratory volume (FEV1.0) after pneumonectomy is less than 900 ml/m2, we'll be likely to try this angioplastic procedure at first.     

Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting

BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.     

Longterm followup (12-15 years) of a randomized controlled trial comparing Bassini-Stetten, Shouldice, and high ligation with narrowing of the internal ring for primary inguinal hernia repair

OBJECTIVE: To determine preoperative and perioperative risk factors for gastrointestinal (GI) complications following cardiac surgery. DESIGN: A database including records of patients who underwent cardiac surgery was reviewed, with univariate analysis of several variables thought to be relevant to GI complications. Using a risk-adjusted model, preoperative stratification was used to fit a logistic regression model including operative features. SETTING AND PATIENTS: All patients undergoing cardiac surgery from January 1, 1991, to December 31, 1994, at a university-affiliated teaching hospital. MAIN OUTCOME MEASURES: Incidence of GI complications, postoperative mortality, length of hospital stay, and relative risk of GI complications based on multivariate analyses. RESULTS: Gastrointestinal complications occurred in 2.1% of patients and had an associated mortality of 19.4%; this was higher than the mortality in patients without GI complications (4.1%; P < .001). Length of hospital stay was significantly longer in patients with GI complications (43 vs 13.4 days; P < .001). In patients who underwent coronary artery bypass grafting only, cardiopulmonary bypass time was significantly longer in patients with GI complications (166 vs 138 minutes; P = .004). In patients who underwent valve replacement, bypass time was not associated with GI complications. Use of a left internal mammary artery graft was associated with a lower incidence of GI complications. CONCLUSIONS: Patients who have GI complications after cardiac surgery have a higher mortality and a longer hospital stay. The use of a left internal mammary artery seems to have a protective effect against GI complications. Based on these observations, patients may be stratified into low-, medium-, and high-risk groups.     

Innovative uses of saphenous vein grafts in minimally invasive coronary surgery

STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure.     

Current status of malaria infection in a southeastern province of Lao PDR

OBJECTIVE: The authors reviewed the hemorrhagic complications of patients who underwent pancreatoduodenectomies between 1972 and 1996. SUMMARY BACKGROUND DATA: Although recent studies have demonstrated a reduction in the mortality of pancreatic resection, morbidity is still high. Bleeding is a close second to anastomotic dehiscence in the list of dangerous postoperative complications. METHODS: The medical records from a prospective data bank of 559 patients who underwent pancreatic resection at the Surgical Clinic of Mannheim (Heidelberg University) were analyzed in regard to postoperative hemorrhagic complications. Differences were evaluated with the Fisher exact test. RESULTS: The overall mortality rate was 2.7%. Postoperative bleeding occurred in 42 patients (7.5%), with 6 episodes ending fatally (14.3%). Erosive bleeding after pancreatic leak was noted in 11 patients (26.2%), 4 of whom died. Gastrointestinal hemorrhage occurred in 22 patients, and operative field hemorrhage was present in 20 cases. Relaparotomy was necessary in 29 patients. An angiography with interventional embolization for recurrent bleeding was performed in three patients. Seven hemorrhages (4.6%) occurred after pancreatectomy for chronic pancreatitis and 35 episodes of bleeding (8.6%) were encountered after pancreatectomy for malignant disease. Obstructive jaundice was present in 359 patients (63.9%). In this group of patients, 32 (8.9%) postoperative hemorrhages occurred. Preoperative biliary drainage did not influence the type and mortality rate of postoperative hemorrhage in jaundiced patients. CONCLUSION: The prevention of these bleeding complications depends in the first place on meticulous hemostatic technique. Preoperative biliary drainage does not lower postoperative bleeding complications in jaundiced patients. Continuous, close observation of the patient in the postoperative period, so as to detect complications in time, and expeditious hemostasis are paramount.