Long-term follow-up of positive cultures in 500 abdominal aortic aneurysms

The surgical management of regional nodes in patients with cancer has been controversial for many years. This paper reviews the role of elective lymph node dissection in the management of malignant melanoma. The evidence for and against elective lymphadenectomy is discussed and a policy of therapeutic, rather than elective, lymph node excision recommended.     

Stent-graft placement procedures for descending thoracic aortic aneurysms

Descending thoracic aortic aneurysms most often are caused by arteriosclerosis and appear most frequently in elderly males. These patients often are asymptomatic, but they may experience symptoms related to compression of adjacent thoracic structures, or they may present for treatment when their-aneurysms rupture. Open surgical resections and repairs of descending thoracic aortic aneurysms are associated with bleeding, paraplegia, strokes, renal insufficiency, and the need for prolonged ventilatory support in the postoperative period. At Stanford (Calif) University Hospital, surgeons are placing endovascular stent-grafts in patients with descending thoracic aortic aneurysms who meet specific anatomic selection criteria. This new treatment modality provides patients with a less invasive, less hazardous, and potentially less expensive alternative to open surgical resection and repair procedures. Preoperative teaching and skilled perioperative nursing care are essential for positive patient outcomes with stent-graft treatment of descending thoracic aortic aneurysms.     

Clinical decision making and operative approaches to thoracic aortic aneurysms

The care of the patient with thoracic aneurysms is quite complicated. The decision to treat an aneurysm must be based on the risk of rupture and the patient's life expectancy. The preoperative evaluation must include detailed imaging to allow proper preoperative planning. This is especially important to determine the need for hypothermic circulatory arrest or the potential to treat a descending aneurysm with an endovascular approach. Thorough preoperative preparation and intraoperative care are as important as surgical decision making and meticulous technique. Although significant advances have been made in operative approaches, cerebral and myocardial preservation, and postoperative care, the management of complicated aneurysms of the thoracic aorta is frequently a humbling experience.     

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

PURPOSE: Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). METHODS: The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. RESULTS: Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8, p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively, p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age (p = 0.0001), cerebrovascular disease (p = 0.009), and number of days on mechanical ventilation (p = 0.01) to be independent prognostic determinants of late survival in group I. CONCLUSIONS: Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified.     

Magnetic resonance imaging in the diagnosis and follow-up of false aneurysms after Bentall's operation

The prevalence and natural history of pseudo-aneurysm (PA) following Bentall procedure has not been established. To determine the follow-up of such patients, we report our experience with magnetic resonance imaging (MRI) used since 1988. At first, spin-echo exam, PA was suspected in 19 patients among 27 patients who underwent aortic valve and ascending aortic replacement between 1980 and 1991. Mean PA diameter was < 4 cm in 13 patients (group 1) and > or = 4 cm in six patients (group 2). Two patients of group 1 were lost at follow-up while two others died after the first spin-echo exam, one death being related to PA formation. Repeated MRIs were done in nine patients of group 1 and all patients of group 2 averaging respectively 2.2 +/- 1.1 exams per patient for group 1 and 1.8 +/- 1.1 for group 2. PA regressed in six patients of group 1 and one patient of group 2 thus suggesting thrombosed PA or postoperative haematoma. PA remained stable in two patients of group 1 and one patient of group 2. One patient of group 1 in whom PA increased at follow-up died suddenly. Four patients of group 2 required surgical correction of their PA. One of these patients died of massive hemoptysis 2 months following reintervention. Recently, addition of cine MRI allows visualization of turbulent flow within the PA thus increasing MRI specificity for PA diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical results of endovascular stent graft repair for fifty cases of thoracic aortic aneurysms

Between February 1995 and December 1997, 50 cases (55 lesions) of thoracic aortic aneurysms including 20 cases of aortic dissections were treated with an endovascular technique using the stent grafts. All patients were treated in the operating room under general anesthesia and the stent grafts were implanted through 18 Fr. or 20 Fr. sheaths via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in 53 of 55 lesions (delivery success rate: 96.4%). Exclusion of the aneurysms and entry closing without endoleak were achieved within two weeks after the operation in 43 of 53 lesions (initial success rate: 81.1%). Endoleak was found in 10 lesions (minor endoleak: 8 and major endoleak: 2 lesions). Two patients died in the periopertive period of delivery failures as injury to external iliac artery and damage to the delivery sheath caused by tortuous and narrow access routes. Endovascular stent graft repair of thoracic aortic aneurysms is minimally invasive operation in comparison with conventional surgical graft replacement with extracorporeal circulation. These early results suggest that the stent graft repair is possibly safe and useful treatment for the patients of thoracic aortic aneurysms especially in high risk patients. However, careful long-term follow-up is necessary to prove the value and the effects of this endovascular treatment and improvement of the stent graft system and technical training of endovascular surgery for operators are required to reduce the delivery failure and to determine the stent graft repair is reliable treatment.     

Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age

PURPOSE: To study the clinical histories and courses of six patients with choroidal neovascularization secondary to endogenous Candida albicans chorioretinitis. METHODS: The medical records, fundus photographs, and fluorescein angiograms of six patients who developed C. albicans chorioretinitis secondary to candidemia and who subsequently developed choroidal neovascularization in one or both eyes were reviewed. RESULTS: The six patients ranged in age from 18 to 79 years. Four were women and two men; all but one showed evidence of bilateral chorioretinal scarring secondary to C. albicans chorioretinitis. All patients had been treated successfully with systemic antifungal therapy (amphotericin B). Two weeks to two years after the chorioretinitis, choroidal neovascularization developed in one eye (four cases) or both eyes (two cases). The neovascularization on initial examination was subfoveal in four eyes, extrafoveal in three eyes, and juxtafoveal in one eye. Laser photocoagulation was used in four of the eight involved eyes. In these cases, the active choroidal neovascularization was brought under control. In one eye, the patient had submacular surgery for excision of the choroidal neovascular membrane. Final visual acuities ranged from 20/20 to 20/200 in treated eyes and from 20/50 to 20/400 in untreated eyes. CONCLUSION: Choroidal neovascularization is a potential cause of late visual loss in patients who have had C. albicans sepsis and endogenous C. albicans chorioretinitis. Eyes that have chorioretinal scarring from C. albicans chorioretinitis should be watched for the development of choroidal neovascularization. Laser photocoagulation or perhaps surgical excision of the neovascular complex may be of benefit in selected cases.     

Preservation of masculine sexual functions after treatment for abdominal aortic aneurysms

Preserving sexual function is an important objective in the treatment of aneurysms of the abdominal aorta in men. METHOD: Two groups of patients with normal sexual function were operated for aneurysms of the abdominal aorta. In group 1 (n = 22) a small opening in the infra-renal aorta was made for insertion of an aorto-bi-iliac prosthesis; in 4 of them, the aneurysm was not opened but simply excluded. In group 2 (n = 22), the aorta was opened longitudinally for insertion of an aorto-aortic tube. RESULTS: Sexual function was totally abolished after operation in 9% of the patients in group 1 and in 36% of those in group 2. Sexual functions were totally preserved in 50% of the patients in group 1 and in 36% of those in group 2, but the differences were not statistically significant. CONCLUSIONS: 1) It is not always possible to guarantee maintained sexual function after operation for aneurysms of the abdominal aorta and the patients should be advised thereto; 2) aortobi-iliac prostheses with limited opening of the aorta in the upper part of the aneurysm or exclusion of the aneurysm led to a higher rate of preservation than aorto-aortic tubes with total opening of the aneurysm and should be preferred in men with normal sexual function.     

Redo operation after surgery for aortic aneurysm and dissection

Thirteen patients who underwent redo operation after surgical treatment of aortic aneurysm and dissection were presented. In 8 patients, redo operations were performed for aortic dissection following aortic valve replacement. A-C bypass, the Koster-Collins operation and replacement of thoracic aorta. In the other 5 patients, the reasons for redo operation were aortic root enlargement after replacement of ascending aorta and aortic valve replacement, pseudoaneurysm and aneurysmal dilatation around coronary button for the Bentall operation and recurrent aneurysm after patch aortoplasty and thoracoabdominal replacement using the Crawford's maneuver. To prevent these redo operation, adequate selection of surgical procedures and meticulous operative techniques should be required in primary operation.     

Long-term follow-up after primary extracorporeal shockwave lithotripsy monotherapy of staghorn calculi: results after more than 6 years

OBJECTIVE: We retrospectively investigated 58 patients suffering from 60 staghorn calculi, who were treated with primary extracorporeal shockwave lithotripsy (ESWL) monotherapy, in order to determine long-term results and the fate of the residual stones. MATERIAL AND METHODS: Mean follow-up was 72.4 months. There were 49 partial staghorn calculi (C4) and 11 complete C5 stones according to Rocco's classification. The mean number of ESWL sessions needed for disintegration was 3.6. The mean amount of shockwaves was 10,244. ESWL monotherapy alone was performed in 26 staghorn calculi (43.3%). In treating the other 34 staghorn calculi 56 auxiliary procedures were necessary. RESULTS: At discharge 28.3% of the patients were free of stones. Fifty-five percent had small remnant particles (< 4 mm) and 16.7% had rest-fragments (> 4 mm). After a mean follow-up period of 72.4 months 36 patients were free of stones (60%). Twenty-four patients still have residual stones. The fragments in 2 patients did not change in size, in 14 patients fragments became bigger and 8 patients had a real recurrence (13.3%). CONCLUSIONS: Primary ESWL monotherapy of staghorn calculi is justified because of the comparable results with open surgery and percutaneous nephrolithotomy (PCNL). Prognostic good factors are small stone mass with most of the stone mass in the upper and middle calices, the absence of dilatation and the absence of anatomical anomalies.     

Long-term results of Watson-Jones tenodesis of the ankle. Clinical and radiographic findings after ten to eighteen years of follow-up

Thirty-seven chronically unstable ankles in thirty-six patients were operated on with use of a Watson-Jones tenodesis. Thirty-four ankles (thirty-three patients) were followed for a mean duration of thirteen years and eight months (range, ten to eighteen years) after the operation. There were nine male and twenty-four female patients. The mean age of the patients was thirty-one years (range, fourteen to fifty-seven years) at the time of the operation and forty-four years (range, twenty-eight to seventy years) at the time of the latest follow-up. At the time of the most recent follow-up evaluation, twenty-seven patients (twenty-eight ankles) were examined directly by one of us and twenty-five patients (twenty-six ankles) also were evaluated radiographically. The other six patients were interviewed, with use of a questionnaire, by telephone. Of the thirty-four ankles, nineteen had an excellent result (grade 1), eleven had a good result (grade 2), three had a fair result (grade 3), and one had a poor result (grade 4) according to the rating system of Good et al. The mean score (and standard deviation) on the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society for the twenty-eight ankles that were examined directly by one of us was 90 +/- 9.3 points (range, 68 to 100 points). Progression of an exostosis at the edge of the joint was detected in eighteen (69 percent) of the twenty-six ankles that were examined radiographically, but narrowing of the joint space was not seen in any ankle. No relationship was detected between the clinical results and radiographic osteoarthrotic changes or the duration of follow-up. The results did not deteriorate over the long term.     

Outcome after trans-tibial amputation for vascular disease. A follow-up after eight years

Steps to encourage clinicians to adopt the best practices for communicating bad news to patients are outlined. First, official, credible guidelines endorsed by key organizations or professional bodies, giving a clear message about the components and importance of the best practices, must be produced. Second, the guidelines should be disseminated; publication in journals or mailing to clinicians is unlikely to be sufficient. Third, clinicians should be provided with feedback on whether their performance meets established standards. This requires acceptable systems to collect valid and reliable performance data. Fourth, clinicians need contingencies for providing best practice care. Fifth, barriers to improvement should be explored and strategies to address them, including interactional skills training, implemented. Continuous quality assurance, commitment, and evaluations will help clinicians use the best practices for breaking bad news to patients.     

Long-term follow-up after bowel resection for necrotizing enterocolitis: factors affecting outcome

BACKGROUND: Necrotizing enterocolitis (NEC) is the most common surgical emergency among newborns and is associated with a high morbidity and mortality. This study evaluates the long-term survival of infants requiring surgical intervention for NEC and factors affecting outcome. METHODS: A retrospective review of infants requiring surgery for complications of NEC at a tertiary care, pediatric hospital over a 16-year period was performed. Patients were evaluated for early and late morbidity and mortality, length of intestinal resection, presence of the ileocecal valve (ICV), days of parenteral nutrition (PN), and growth. RESULTS: Two hundred forty-nine patients were included, with an average gestational age of 30 +/- 5 (+/- SD) weeks and birth weight of 1.50 +/- 0.89 kg. The surgical mortality rate was 45%, with survivors (137) being larger (P < .001) and older (P < .001) at time of birth than nonsurvivors. Mortality rates varied inversely with gestational age and birth weight. Surgical survivors had an average of 21 +/- 26 cm of intestinal length resected. The ileocecal valve was preserved in 45% of infants. Growth was similar between infants with or without an ICV. Stratification of length of intestine resected showed that infants with larger resections had greater requirements for parenteral nutrition, but this had no influence on long-term growth at follow-up. CONCLUSIONS: Survivors of NEC are characterized by greater gestational age, greater birth weight, and older postgestational age at surgery. Infants who underwent greater intestinal resections required longer periods of PN. The length of intestine resected or presence of the ileocecal valve had no overall bearing on long-term outcome.