Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts.

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.

Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair?

Ninety patients with esophageal perforations were operated on at our institutions between 1970 and 1992. Thirty-four of them were seen after delayed diagnosis (> 24 hours) with mediastinal sepsis caused by perforation of the thoracic esophagus. There were 18 patients with spontaneous ruptures, 11 with instrumental perforations (including one caused during laparotomy), and 3 perforations caused by foreign bodies. One patient had perforation of an esophageal ulcer into the pericardium and another had perforation of an esophageal diverticulum into the mediastinum. Nineteen patients underwent primary repair of the perforation with cleansing and drainage of the mediastinum and the pleural cavity. The remaining 15 had primary extirpation of the thoracic esophagus, irrigation of the mediastinum with antibiotics, cervical esophagostomy, gastrostomy, and drainage of the mediastinum and pleural cavity. Nineteen of the 34 patients survived (hospital mortality 44%). Of patients with primary repair, only six survived (in-hospital mortality 68%), whereas only two patients treated with esophagectomy died (in-hospital mortality 13%). The difference was highly significant (p = 0.001). The most common cause of death was multiorgan failure resulting from sepsis. Postoperative complications developed in four patients treated with primary repair (two sepsis, one empyema, and one anuria) and in seven patients treated with esophagectomy (two empyema, two sepsis, one pneumonia, one mediastinal abscess, and one brain abscess). After healing of the mediastinitis, the esophagogastric continuity was reconstructed with colon in 11 patients and stomach in two patients. In the management of delayed esophageal perforation with mediastinal sepsis, esophagectomy is superior to primary repair alone, which often leads to mediastinal leakage, continued sepsis, and death.

Treatment of severe peptic esophageal stricture with Roux-en-Y partial gastrectomy, vagotomy, and endoscopic dilation. A follow-up study.

Eleven patients with dysphagia caused by severe esophageal stricture (length 2 to 10 cm) resulting from reflux esophagitis were treated with fibroendoscopic dilation (Eder-Puestow) and Roux-en-Y partial gastrectomy with vagotomy during 10 years (1979 to 1988). There was no operative mortality, but complications developed in three patients: One patient had a mediastinal abscess demanding thoracotomy as a result of esophageal perforation after dilatation; one had postoperative pneumonia; and one patient had ileus. After a mean follow-up of 4 years (range 1 to 10 years) esophagitis healed in all cases, as judged by endoscopy. Eight patients were asymptomatic, but three had slight transient dysphagia. Postoperatively one to eight dilations (average three to four) were needed to relieve dysphagia in the first postoperative year, but later the stricture healed in every case. Postoperative pH measurement was performed in six latest patients and showed complete absence of reflux in all cases. It is concluded that Roux-en-Y partial gastrectomy with vagotomy and endoscopic dilation is an effective, simple, and safe procedure in the management of severe peptic esophageal (acid or alkaline esophagitis) stricture. However, occasional postoperative dilations at the outpatient clinic are often needed in severe cases in the first postoperative year.

Dilatation of ascending aorta in patients with repaired coarctation.

The long-term outcome following repair of typical aortic coarctation in adulthood may be complicated by disorders of the ascending aorta. Follow-up averaging 15 years revealed a 3.8% incidence of dilatation of the ascending aorta after such late repair. Hypertension and concomitant aortic valvular disease were common in these patients. Aortic dilatation can appear years after coarctation repair, irrespective of the operative technique and its success, and can lead to death from aortic dissection or rupture of an aortic aneurysm. Careful follow-up after coarctation repair in adulthood is advisable to detect late aortic complications.

Hematuria is an indication of rupture of an abdominal aortic aneurysm into the vena cava.

During a period of 13 years 11 patients were operated on because of a spontaneous aortocaval fistula caused by a ruptured abdominal aortic aneurysm. The classic diagnostic signs of an aortocaval fistula (pulsatile abdominal mass with bruit and high output heart failure) were present in approximately half of the patients, whereas hematuria was a constant finding in all patients. Six patients had macrohematuria, and five had microhematuria. Seven patients (64% survived, and four had postoperative complications: 1 ileus, 2 postoperative pneumonias, 2 deep venous thrombosis, 1 postoperative hemorrhage. The mean operative blood loss was 7 L. After operation the average follow-up time was 4 years. In four patients who died the perioperative (within 30 days) causes of death were renal failure, a bleeding duodenal carcinoma, myocardial infarction, and operative bleeding. It is concluded that hematuria is a more frequent finding than earlier assumed among patients whose abdominal aortic aneurysm has ruptured into the vena cava. The presence of hematuria in a patient suffering from an abdominal aortic aneurysm is an indication for aortography to rule out an aortocaval fistula.

Abdominal complications following cardiopulmonary bypass in open-heart surgery.

Open-heart surgery was performed on 1686 adult patients between 1980 and 1984, with a mortality rate due to abdominal complications of 0.6%. Every operation involved the use of cardiopulmonary bypass (CPB). Abdominal complications occurred in 1.6%, with an overall mortality rate of 36%. The most frequent complication was gastrointestinal (Gl) bleeding (61%). The mortality of the patients who bled from the Gl tract was 53%. Other complications encountered were gastroduodenal ulcer, colitis, ileus, subphrenic abscess and intraperitoneal bleeding. Prolonged CPB and low output syndrome preceded multiple organ failure, which occurred in 39% of those who had abdominal complications and in 59% of those who bled. Gl bleeding after CPB did not correlate with a previous history of gastric ulcer. Reoperation because of cardiac tamponade or excessive chest tube drainage was a factor predisposing to Gl bleeding. The mortality and abdominal complication rates were significantly higher in valve surgery than in coronary revascularization.

Esophago-pericardial fistula. A case report and review of the literature.

A case of esophago-pericardial fistula is described which was treated successfully by pericardial drainage and closure of the fistula 12 days after perforation. The condition is rare and often fatal. In 29 reported cases there were only 5 survivors. On the basis of our observation and a review of the literature it is concluded that the first step in the treatment should be pericardial drainage and antibiotic coverage, followed by elective operative closure of the fistula.