The Ross Operation in the Adult: What, Why, and When?

The normal aortic valve is a sophisticated and dynamic structure whose equal replacement has not yet been actualized by modern technology. The use of the pulmonary autograft as a substitute for a diseased aortic valve (the Ross procedure) has been in practice for several decades in many types of patient. In the adult, it has not been adopted widely due to concerns about its technical challenge, complex perioperative care, the development of pulmonic valve disease, and concerns about long-term dilatation of the neo-aortic root, among others. There has been a substantial body of data showing excellent long-term survival, freedom from reoperation, and quality of life, in contradistinction to these preconceptions. The authors review the available data pertinent to these questions to further define the role of the Ross procedure in the adult cardiac surgery patient.

The HYSLAR trial: a prospective randomized controlled trial of the use of a restrictive fluid regimen with 3% hypertonic saline versus lactated Ringers in patients undergoing pancreaticoduodenectomy.

OBJECTIVE: This study was designed to determine whether the volume and type of fluid administered for pancreaticoduodenectomy impacts postoperative outcomes. BACKGROUND: Three percent hypertonic saline (HYS) has been suggested as a means of reducing the volume of fluid required to sustain tissue perfusion in the perioperative period. METHODS: Between May 2011 and November 2013, patients undergoing pancreaticoduodenectomy were enrolled in an institutional review board-approved, single-center, prospective, parallel, randomized controlled trial (NCT 01428050), comparing lactated Ringers (LAR) (15 mL/kg/hr LAR intraoperation, 2 mL/kg/hr LAR postoperation) with HYS (9 mL/kg/hr LAR and 1 mL/kg/hr HYS intraoperation, 1 mL/kg/hr HYS postoperation). RESULTS: A total of 264 patients were randomized. Demographic variables between groups were similar. The HYS patients had a significantly reduced net fluid balance (65 vs 91 mL/kg, P = 0.02). The overall complication rate was reduced in the HYS group (43% vs 54%), with a relative risk of 0.79 [95% confidence interval (CI), 0.62-1.02; P = 0.073], factoring stratification for pancreas texture. After adjustment for age and weight, the relative risk was 0.75 [95% CI (0.58-0.96); P = 0.023]. The total number of complications was significantly reduced in the HYS group (93 vs 123), with an incidence rate ratio of 0.74 [95% CI (0.56-0.97); P = 0.027]. After adjustment for age and weight, the incidence rate ratio was 0.69 [95% CI (0.52-0.90); P = 0.0068]. Reoperations, length of stay, readmissions, and 90-day mortality were similar between groups. CONCLUSIONS: A moderately restrictive fluid regimen with HYS resulted in a statistically significant 25% reduction in complications when adjusted for age, weight, and pancreatic texture.

Double jeopardy: Successful management of a traumatic ascending aortic pseudoaneurysm with concurrent subdural hematoma.

We present the case of a 59-year-old male who sustained an ascending aortic injury and a subdural hematoma after a head on collision. After undergoing emergent craniotomy for evacuation of the subdural hematoma, he was maintained with strict blood pressure control. Once able to be safely anticoagulated, he underwent replacement of the ascending aorta. This exceedingly rare case was managed by a multidisciplinary team approach that led to an optimal outcome given his disastrous multi-traumatic injuries.

Missed opportunities: clinical antecedents in the diagnosis of advanced breast cancer.

BACKGROUND: Locally advanced breast cancer (LABC) often requires complex treatment, and the prognosis is typically poor. We hypothesize that LABC patients engage the healthcare system with a variant pattern as compared with patients diagnosed with early stage disease. METHODS: We identified all newly diagnosed breast cancer patients between 2005 and 2009 at Kings County Hospital (KCH), focusing upon established patients. All provider encounters during 2 years before diagnosis were retrieved from the medical record. Patients were stratified to two groups: early breast cancer (n = 87) and LABC (n = 44). Encounters were classified by type of clinic and whether a clinical breast examination or breast imaging study was performed. RESULTS: The early group made more total contacts with the healthcare system than LABC group, 10.4 and 7.4, respectively. Both groups demonstrated statistically equivalent rates of contact with subspecialty and acute providers. Early patients demonstrated greater usage of primary care services, 4.6 compared with 3.0 visits among LABC patients. The early cohort demonstrated increased rates of breast imaging and examinations overall as well as an increased rate of breast examination within primary care clinics. DISCUSSION: Delayed breast cancer diagnosis is influenced by patterns of healthcare utilization and the effectiveness of primary care services. LABC patients are less likely to visit primary care clinics despite frequent contacts with the healthcare system and as such are less likely to receive basic diagnostic procedures, including clinical breast examination and mammography. Renewed attention to these primary care activities should detect many LABC patients at an earlier stage.

Accuracy and reliability of three different techniques for manual goniometry for wrist motion: a cadaveric study.

PURPOSE: Despite the ubiquitous use of manual goniometry in measuring objective outcomes of hand surgery and therapy, there are limited data concerning its accuracy or repeatability for wrist motion. The purpose of this study was to evaluate the accuracy and reliability (both inter- and intra-rater) in measuring wrist flexion and extension using 3 manual goniometric alignment techniques (ulnar, radial, and dorsal-volar) in cadaveric upper extremities, using fluoroscopic verification of posture as a gold standard. In addition, we sought to assess the accuracy and reliability of the dorsal-volar technique for measurement of radioulnar deviation. METHODS: External fixators were applied to 10 cadaveric wrists with intramedullary cannulated rods in the radius and third metacarpal for gold-standard fluoroscopic verification of posture. Manual goniometric measurements with each technique were captured by 2 raters (a hand surgeon and a hand therapist) for reliability measurements and by a single rater for accuracy. Wrists were positioned at angles of maximum flexion, extension, and radial and ulnar deviation for reliability testing and at preselected angles across the range of motion for accuracy testing. At each position, wrist angle was measured with a 1 degrees increment goniometer, and fluoroscopic angles were measured digitally. Intraclass correlation coefficients and root mean square values were calculated for all combinations, and analysis of variance was used to test differences between techniques. RESULTS: No technique was statistically less accurate than any other (6 degrees to 7 degrees ). Each method was found to have high intra-rater reliability. For measurement of wrist flexion and extension, the dorsal-volar technique demonstrated the greatest inter-rater reliability, as compared to ulnar and radial, respectively. CONCLUSIONS: Although each measurement technique demonstrated a similar degree of accuracy and intra-rater reliability, the dorsal-volar technique demonstrates the greatest level of inter-rater reliability for measurement of wrist flexion and extension. This information is important clinically, as measurements are regularly exchanged between hand surgeons and therapists as a basis for decisions regarding patient care.

Predicting the risk of death following coronary artery bypass graft made simple: a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database.

INTRODUCTION: Risk models to predict 30-day mortality following isolated coronary artery bypass graft is an active area of research. Simple risk predictors are particularly important for cardiothoracic surgeons who are coming under increased scrutiny since these physicians typically care for higher risk patients and thus expect worse outcomes. The objective of this study was to develop a 30-day postoperative mortality risk model for patients undergoing CABG using the American College of Surgeons National Surgical Quality Improvement Program database. MATERIAL AND METHODS: Data was extracted and analyzed from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2010). Patients that had ischemic heart disease (ICD9 410-414) undergoing one to four vessel CABG (CPT 33533-33536) were selected. To select for acquired heart disease, only patients age 40 and older were included. Multivariate logistic regression analysis was used to create a risk model. The C-statistic and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the model. Bootstrap-validated C-statistic was calculated. RESULTS: A total of 2254 cases met selection criteria. Forty-nine patients (2.2%) died within 30 days. Six independent risk factors predictive of short-term mortality were identified including age, preoperative sodium, preoperative blood urea nitrogen, previous percutaneous coronary intervention, dyspnea at rest, and history of prior myocardial infarction. The C-statistic for this model was 0.773 while the bootstrap-validated C-statistic was 0.750. The Hosmer-Lemeshow test had a p-value of 0.675, suggesting the model does not overfit the data. CONCLUSIONS: The American College of Surgeons National Surgical Quality Improvement Program risk model has good discrimination for 30-day mortality following coronary artery bypass graft surgery. The model employs six independent variables, making it easy to use in the clinical setting.

Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery†.

Management of anemic patients refusing blood transfusion remains challenging. Concomitant coronary artery disease further complicates management. We sought to decrease the likelihood of cardiac events by employing hypothermia and neuromuscular blockade, in addition to limited phlebotomy, in a critically anemic Jehovah's Witness patient following emergent colectomy. The patient's hemoglobin concentrations were trended with serial blood gases. Neuromuscular blockade was instituted with cisatracurium, followed by hypothermia to a target of 32°C. The patient's lowest hemoglobin levels occurred on postoperative day 3 before beginning to rise. There were no postoperative cardiac events reported during the patient's course of stay. She recovered well with no evidence of anemia or cardiac events at 1-year follow-up. We conclude that targeted hypothermia with neuromuscular blockade, as an adjunct to accepted techniques, may be an alternative for critically anemic patients with coronary artery disease refusing blood transfusion.

A dual-institution randomized controlled trial of remnant closure after distal pancreatectomy: does the addition of a falciform patch and fibrin glue improve outcomes?

OBJECTIVE: The objective of the study was to assess the efficacy of two pancreatic remnant closure techniques following distal pancreatectomy: (1) stapled or sutured closure versus (2) stapled or sutured closure plus falciform patch and fibrin glue reinforcement in the setting of a prospective randomized trial, with the primary endpoint being pancreatic fistula. Pancreatic stump leak following left-sided pancreatic resection (distal pancreatectomy) remains common. Despite multiple and varied techniques for closure, the reported leak rate varies up to 30 %. A retrospective analysis by Iannitti et al. (J Am Coll Surg 203(6):857-864, 2006) detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fibrin glue. METHODS: Between April 2008 and October 2011, all willing patients scheduled to undergo distal pancreatectomy at the authors' institutions were consented and enrolled at the preoperative office visit. Patients were intraoperatively stratified as having hard or soft glands and randomized to one of two groups: (1) closure utilizing stapling or suturing (SS) versus (2) stapled or sutured plus falciform ligament patch and fibrin glue (FF). The trial design and power analysis (α = 0.05, ß = 0.2, power 80 %, chi-square test) hypothesized that the FF intervention would reduce the primary endpoint (pancreatic fistula) from 30 % to 15 % and targeted an accrual goal of 190 patients. Secondary endpoints included length of postoperative hospital stay, 30-day mortality, hospital readmission, and ISGPF fistula grade (A, B, and C). RESULTS: The trial accrued 109 patients, 55 in the SS group and 54 in the FF group. Enrollment was closed prior to the target accrual, following an interim analysis and futility calculation. Due to insufficient enrollment, patients stratified as having a hard gland were excluded (n = 8) from analysis, leaving 101 patients in the soft stratum. The overall pancreatic leak rate was 19.8 % (20 patients) for patients with soft glands. Patients randomized to the FF group had a leak rate of 20 %, as compared with 19.6 % in the SS group (p = 1.000). Fistula grades in both groups were identical: 1A, 8B, and 1C in the FF group as compared to 1A, 8B, and 1C in the SS group. Complication rates were comparable between the two groups. The median length of postoperative hospital stay was 5 days in both groups. There was a trend towards a higher 30-day readmission rate in the FF group (28 % vs. 17.6 %, p = 0.243). CONCLUSION: The addition of a falciform ligament patch and fibrin glue to standard stapled or sutured remnant closure did not reduce the rate or severity of pancreatic fistula in patients undergoing distal pancreatectomy (ClinicalTrials.gov NCT00889213).

Flexor tenosynovitis caused by Mycobacterium scrofulaceum: case report.

Atypical hand infections with Mycobacterium species are uncommon, and Mycobacterium scrofulaceum infections are rare. We present a case of flexor tenosynovitis caused by M scrofulaceum in a 66-year-old man with hypertension and diabetes.

Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty.

UNLABELLED: Deep venous thrombosis and pulmonary embolism after shoulder arthroplasty are not well described. We sought to identify the frequency of deep venous thrombosis and pulmonary embolisms in patients after shoulder arthroplasties to compare these rates with the frequency of deep venous thrombosis and pulmonary embolisms among patients who had total hip and total knee arthroplasties, and to identify associated risk factors. The New York State Department of Health Statewide Planning and Research Cooperative System database was used to identify hospital admissions of patients having shoulder, hip, or knee arthroplasties between 1985 and 2003 with or without an associated diagnostic code for deep venous thrombosis or pulmonary embolism. This resulted in a retrospective cohort of 328,301 procedures. The frequency of deep venous thrombosis was 5.0 per 1000 procedures for shoulder arthroplasties compared with 15.7 for hip arthroplasties and 26.9 for knee arthroplasties. The frequency of pulmonary embolisms was 2.3 for shoulder arthroplasties, 4.2 for hip arthroplasties, and 4.4 for knee arthroplasties. Increasing age, trauma, and cancer were risk factors for thromboembolic events after shoulder arthroplasties. Although the absolute rates of thromboembolic complications were less in patients who had shoulder arthroplasties compared with those of patients who had lower extremity procedures, a larger percentage of these complications were pulmonary embolisms. Perioperative antithrombotic prophylaxis may be beneficial to reduce the frequency of deep venous thrombosis and pulmonary embolisms among patients having shoulder arthroplasties, particularly in higher-risk groups. LEVEL OF EVIDENCE: Prognostic study, Level II (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.