The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts.

OBJECTIVES: Although there are numerous reports comparing saphenous vein (SV) and polytetrafluoroethylene (PTFE) with respect to the patency rates for femoropopliteal bypass grafts, the clinical consequences of failed grafts are not as well described. This study compares the outcomes of failed SV and PTFE grafts with a specific emphasis on the degree of acute limb ischemia caused by graft occlusion. METHODS: Over a 6-year period, 718 infrainguinal revascularization procedures were performed, of which 189 were femoropopliteal bypass grafts (SV, 108; PTFE, 81). Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) standardized runoff scores were calculated from preoperative arteriograms. Clinical categories of acute limb ischemia resulting from graft occlusion were graded according to SVS/ISCVS standards (I, viable; II, threatened; III, irreversible). Primary graft patency and limb salvage rates at 48 months were calculated according to the Kaplan-Meier method. RESULTS: Patients were well matched for age, sex, and comorbidities. Chronic critical ischemia was the operative indication in most cases (SV, 82%; PTFE, 80%; P =.85). Runoff scores and preoperative ankle-brachial index measurements were similar for the two groups (SV, 6.0 +/- 2.5 [SD] and 0.51 +/- 0.29; PTFE, 5.3 +/- 2.8 and 0.45 +/- 0.20; P =.06 and P =.12). The distal anastomosis was made below the knee in 60% of SV grafts and 16% of PTFE grafts (P <.001). Grade II ischemia was more likely to occur after occlusion of PTFE grafts (78%) than after occlusion of SV grafts (21%; P =.001). Emergency revascularization after graft occlusion was required for 28% of PTFE failures but only 3% of SV graft failures (P <.001). Primary graft patency at 48 months was 58% for SV grafts and 32% for PTFE grafts (P =.008). Limb salvage was achieved in 81% of SV grafts but only 56% of PTFE grafts (P =.019). CONCLUSIONS: Patients undergoing femoropopliteal bypass grafting with PTFE are at greater risk of ischemic complications from graft occlusion and more frequently require emergency limb revascularization as a result of graft occlusion than patients receiving SV grafts. Graft patency and limb salvage are superior with SV in comparison with PTFE in patients undergoing femoropopliteal bypass grafting.

The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia.

BACKGROUND: Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing. METHODS: From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment. Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length two standard deviations below the mean for height was considered abnormally short. RESULTS: In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barrett's esophagus was the most sensitive test for predicting the need for a lengthening procedure. CONCLUSIONS: Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with other parameters are needed.

Laparoscopic repair of a Morgagni hernia.

Morgagni hernias are unusual diaphragmatic hernias which usually present in adulthood. They have traditionally been repaired through transabdominal or transthoracic approaches. The authors present a case of a laparoscopic repair of a Morgagni hernia in a 52-year-old female. A tension free repair of the defect was accomplished utilizing Goretex (W.L. Gore & Associates, Inc., North Elkton, MD) mesh. The patient had an uneventful recovery and is asymptomatic at 6 months follow-up. The etiology, diagnosis and traditional surgical approaches to this problem are discussed. A technique for laparoscopic repair of a Morgagni hernia is described. The literature on the laparoscopic repair of a Morgagni hernia is reviewed and different operative techniques are discussed.

A combined laparoscopic-endoscopic method of assessment to prevent the complications of short esophagus.

As antireflux surgery has been used increasingly for gastroesophageal reflux disease (GERD), a need has arisen for an accurate method to assess esophageal length. There are a number of preoperative tests that can help surgeons to establish the presence of a short esophagus, but intraoperative assessment after esophageal mobilization is the standard method. In this era of laparoscopic surgery, the surgeon mobilizes the esophagus extensively from the abdomen and then determines if mobilization is sufficient. We report an intraoperative technique that combines laparoscopic with endoscopic methods to determine the position of the gastroesophageal junction. Because two physicians are required, there is additional operating room time, resulting in increased costs. However, these costs are offset by the assurance that the complications of the short esophagus can be avoided. With experience, modifications were made, resulting in the technique described herein.

Symptom priority ranking in the care of gastroesophageal reflux: a review of 1,850 cases.

BACKGROUND: Clinical history remains an important part of the medical evaluation of patients with gastroesophageal reflux disease (GERD). Heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD. Priority rankings of these symptoms can be determined with a standardized questionnaire. OBJECTIVE: To determine whether symptom priority ranking and symptom severity grading can provide useful information in the evaluation of patients with GERD. METHODS: From 1,850 patients that were analyzed retrospectively, patients with dysphagia unrelated to GERD were excluded. A standardized questionnaire was applied before each patient underwent any esophageal diagnostic study. Priority of symptoms was determined to be primary, secondary, tertiary, or none based on the patient response to the questionnaire. Presence of a stricture was determined either by endoscopy, esophagraphy, or both studies. Stationary esophageal manometry and 24-hour pH monitoring were performed on all patients. Through bivariate and multivariate analysis, the relationships among typical GERD symptoms, esophageal reflux-related stenosis, lower esophageal sphincter pressure, and composite score were established. RESULTS: High priority ranking of the symptom dysphagia is predictive of the presence of an esophageal stricture, but has a negative association with abnormal manometric and pH studies. In contrast, high priority ranking of the symptom heartburn and regurgitation are positively associated with abnormal manometric and pH results. CONCLUSIONS: Priority ranking can be a valuable adjunct to objective testing in the evaluation of GERD. In certain clinical situations it can obviate the need for 24-hour pH monitoring.