Laparoscopic ventral hernia repair: does IPOM plus allow to increase the indications in larger defects?

PURPOSE: The laparoscopic ventral hernia repair (LVHR) may have a limit of effectiveness, especially in defects greater than 80 cm2, with a higher recurrence rate which contraindicates this technique. The purpose of this study is to analyze the indication of LVHR determining and comparing the recurrence rate according to defect size in two series. METHODS: We analyzed all patients who underwent LVHR between 2007 and 2017. Patients were divided according to the ring size: < o ≥ 80 cm2 into group one (G1) and group two (G2) respectively. In both groups, all three techniques were used: intraperitoneal onlay mesh (IPOM), IPOM with closure of the defect (IPOM plus), and IPOM plus + anterior videoscopic component separation (AVCS). RESULTS: A total of 258 patients underwent LVHR. Mean recurrence rate was 13% in G1 and 24% in G2. A statistically significant difference was found when comparing the IPOM technique among both groups, with a higher recurrence rate when ring size was ≥ 80 cm2 (p < 0.5). However, when comparing recurrence rate in IPOM plus and IPOM plus + AVCS between both groups, no significant differences were observed, yielding a p of 0.51 and 0.63, respectively. CONCLUSION: The IPOM technique has shown a limit of effectiveness in large ventral hernia defects. The combination of techniques (ring closure and AVCS) may be useful to expand the indication for this surgery to larger defects and to reduce the recurrence rate. Prospective randomized studies are required to confirm this trend.

[Comparative study of balloon dilatation and stent placement in primary angioplasty]. / Estudio comparativo entre uso de balón y empleo de stents de novo en la angioplastía primaria.

OBJECTIVE: To communicate our results with primary angioplasty (PA) and stenting de novo in acute myocardial infarction. MATERIAL AND METHODS: 163 patients (pts) had clinical diagnosis of MI with an average onset time of symptoms of 2.5 hours. They were divided in two groups: 100 pts with PA using only balloon (group I) and 63 pts with primary stenting (group II) (63 pts with 85 stents). A high pressure technique (14-16 atm) was used in group II and all pts were on salicylic acid and ticlopidine. Both groups were compared. RESULTS: Clinical characteristics, infarct location and infarct related-artery were similar, being left anterior descending the more frequently vessel involved. Clinical success rate was higher in group II (97% vs 87%) and complication rate was threefold higher in group I (9% vs 3%). A mean follow up of 57 months in group I showed a 21% clinical and/or angiographic restenosis rate, while the 12 months follow up in group II failed to show any case of restenosis at all. CONCLUSIONS: The use of stents in PA improves the results achieved with balloon procedures. There is a greater success rate, less complications and better survival patients who had the procedure while being in cardiogenic shock.

[The long-term follow-up of 400 coronary angioplasty patients]. / Seguimiento a largo plazo de 400 pacientes con angioplastía coronaria.

From October 1985 to May 1992, 400 patients had coronary angioplasty of 518 stenotic lesions with a 92% success rate. Mean stenosis was reduced from 88 to 15%. We had 25 major complications (6%): 8 emergency bypass surgery (2%), MI in 12 pts (3%) and 5 deaths (1%). Follow-up was possible in 329 of the 367 patients with a successful procedure (90%), with a mean follow-up of 44 months. We performed coronary angiogram in 113 patients with clinical data suggestive of restenosis, restenosis was found in 73, progression of the coronary atherosclerosis in 18 and 22 (19%) had no evidence of restenosis. A second coronary angioplasty was performed in 44 pts with a 93% success rate, 22 were sent to coronary bypass surgery and medical treatment was given to 7 patients. The 18 pts with progression of the disease were also sent to bypass surgery. During follow-up 25% of the patients required a second angioplasty or bypass surgery. A total of 115 (35%) pts showed evidence of restenosis: in 73 pts (22%) a coronary angiogram revealed restenosis, 12 had angina, 15 myocardial infarction and 15 died of cardiovascular disease. At the end of follow-up 259 pts (79%) were free of myocardial infarction, bypass surgery or cardiovascular death. Survival rate at 3.7 years was 94.5%. In conclusion, coronary angioplasty showed to be safe, effective and with a good long term outcome.

[Coronary angioplasty in 40 patients with 518 stenoses: complications and surgical support]. / Angioplastía coronaria en 400 pacientes con 518 estenosis: complicaciones y soporte quirúrgico.

We analyze the outcome of 400 patients (pts) with coronary angioplasty in 518 stenosis (314 men, age 29 to 80). The clinical syndromes were unstable angina in 252 pts, acute myocardial infarction (MI) in 26, angina or residual ischemia after thrombolysis for MI in 34 and 18 pts with post-MI angina. Success was achieved in 478 of 518 segments (92%). Mean stenosis was reduced from 88 to 15%. Revascularization was complete in 92% of pts. Primary success was 74% in total occlusions. We had 25 major complications (6%): 8 emergency bypass surgery (2%), MI in 12 pts (3%) and 5 deaths (1%). The procedures were performed without surgical standby in 220 pts: in 68 it was an emergency and in 152 it was considered a low risk procedure. Major complications in emergency cases were 3 MI (4%) and 2 deaths (3%). In the low risk procedures there were no deaths, 3 MI (2%) and 1 aortic dissection. We conclude that in well selected patients coronary angioplasty gives a high success rate with very few complications. Furthermore, it is possible to identify a very low risk subset of patients in whom the procedure can be performed without having a surgical standby.

[Primary non-Hodgkin's lymphoma of the duodenum]. / Linfoma não-Hodgkin primário do duodeno.

We report a case of duodenal primary non-Hodgkin lymphoma classified as a polymorphic B lymphoma with a low degree of malignancy. It was studied by ultrasound, computed tomography and simple contrast study. We review the radiologic appearance, sites of origin, and the role of Imagiology in staging and differential diagnosis.

[Coronary angioplasty: experience at the Hospital Español of Mexico City]. / Angioplastía coronaria: experiencia en el Hospital Español de la ciudad de Mexico.

Percutaneous transluminal coronary angioplasty is an accepted treatment for selected patients with ischemic heart disease. This study reports on the primary angiographic success, complications and clinical improvement in our first 22 patients in this institution. Between October 1985 and July 1986 a total of 22 patients, including 15 patients with unstable angina, underwent coronary angioplasty with a total of 37 stenosis greater than or equal to 60%. The number of stenosis per patient varied from one to four. Mean stenosis diameter decreased from 87 +/- 12% to 12 +/- 9% (p less than .00001). Primary success was obtained in 21 patients (95.4%) and in 35 segments (94.5%). In two patients with unstable angina totally occluded vessel was dilated without residual stenosis. One patient in the early stage of a myocardial infarction underwent angioplasty, with 20% residual stenosis and no evidence of necrosis. The only complication related to the procedure was an inferior myocardial infarction in a patient with subtotal obstruction in the distal circumflex. There were no deaths and none of the patients required emergency bypass surgery. Among the 21 patients with successful dilatation, 19 have remained asymptomatic with a mean follow-up of 4.9 +/- 2.5 months. This report shows a high primary success rate and few complications in the first coronary angioplasty procedures performed at our institution. This results need to be confirmed with a greater number of patients and an adequate clinical and angiographic follow-up.

Clinical and angiographic assessment 6 months after double vessel percutaneous coronary angioplasty.

Percutaneous transluminal coronary angioplasty is an accepted treatment for selected patients with single vessel disease but has not been rigorously evaluated in patients with double vessel disease. Among 769 patients undergoing transluminal coronary angioplasty between 1980 and 1984, 74 with double vessel stenosis of 50% or more underwent double vessel coronary angioplasty. Primary success was obtained for both lesions in 63 patients (85%), for one lesion in 11 patients (15%) and for 137 (93%) of 148 segments overall. Except for myocardial infarction in one patient, no serious complication occurred. Before coronary angioplasty, 15 patients had unstable angina, 14 had Canadian Cardiovascular Society class III and 32 class I to II effort angina and only 2 were asymptomatic. Six months after coronary angioplasty, 27 were asymptomatic, 27 had class I to II and 5 had class III effort angina and 2 had sustained an episode of unstable angina. During the follow-up study, two patients had an infarction and one had coronary artery bypass surgery. Coronary arteriography was performed at a mean of 5.5 +/- 2.1 months after coronary angioplasty in all but three patients. Restenosis was found in 30 (23%) of 132 segments with angiographic control. Restenosis was present in one vessel in 17 patients and in both vessels in 4; 40 patients (66%) had no restenosis. Of the 34 patients with definite or probable angina, 50% had restenosis and 19% of patients with restenosis were symptom free.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty for the treatment of variant angina.

Among 268 patients undergoing percutaneous transluminal coronary angioplasty between February 1980 and January 1983, a total of 21 patients had variant angina, documented before angioplasty in 14 and after angioplasty in 7. Before angioplasty, all 21 patients had rest angina and 17 also had effort angina; single vessel coronary artery disease with 60 to 95% stenosis was present in all patients and the left anterior descending coronary artery was involved in all but 3 patients. Coronary angioplasty was successful in 19 patients (90%). Eight of the 19 patients remained symptom-free without coronary restenosis after successful angioplasty; in the other 11 patients, angina reappeared within 4 months, usually in association with restenosis. Of the nine patients with coronary restenosis, six had repeat angioplasty (five successful procedures and one failure), two received medical therapy and one underwent coronary bypass surgery. Patients in whom calcium channel antagonists were discontinued immediately after angioplasty had an exceedingly high coronary restenosis rate (8 [80%] of 10 successful attempts), but when calcium antagonists were continued for an average of 6 +/- 4 months after angioplasty, the restenosis rate was low (3 [21%] of 14 successful attempts). After a mean (+/- SD) follow-up period of 33 +/- 13 months, 1 patient had died and the 20 others (95%) were symptom-free; among these 20, 15 patients (75%) had been taking no antianginal drugs for more than 1 year, 2 still received calcium channel antagonists and 3 had had coronary bypass surgery. Repeat coronary arteriography performed 14 +/- 7 months after angioplasty in the 17 patients without angioplasty-related infarction or surgery showed 50% or less coronary stenosis in 13 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Late arrhythmias in the operated interatrial communication. Analysis of sinus node function and the conduction pathways by His bundle electrocardiography]. / Arritmias tardías en la comunicación interauricular operada. Análisis de la función del nódulo sinusal y de las vías de conducción con eletrocardiografía de His.

Four hundred patients with atrial septal defect treated surgically were reviewed. Thirty five (8.7%) developed arrhytmias post-surgery which persisted for over a year. Sinus bradycardia was found in 10 patients, nodal rhythm in 21, and atrial fibrilation and flutter in 4 patients. Thirty five per cent of the patients with late arrhythmias developed related symptomatology. In 14 patients the function of the sinus node was studied with electrical stimulation of the atrium and with His registry. The interatrial conduction time, AV node and His Purkinje were analized employing various stimulation frequencies. All the cases studied had normal intra-atrial conduction; the response of the atrio-ventricular node to increasing frequencies was normal, an the intraventricular conduction remained constant. In 8 patients (52%), alterations of the sinus node were found; these consisted of prolonged post-stimulation pauses, Wenckebach's type sinoatrial block and suppression of sinus automatism employing vagal procedures or through electrical stimulation. A patient with severe bradycardia detected by dynamic electrocardiography had to be treated with a permanent pacemaker. We confirm that these arrhytmias are not produced by lesions of the internodal tracts, and that an alteration of the sinus node is frequent without a concomitant lesion of the intraventricular pathway. The lesion to the nutrient artery could be due to trauma and/or surgically induced. The response to anticholinergic drugs was good. Prolonged observation of these patients could increase the morbility of these arrythmias and raise doubts of the surgical indications in cases with moderate hemodynamic repercussion.

[Persistent atrioventricular canal. Differential diagnosis of its variations]. / Canal atrioventricular persistente Diagnóstico diferencial de sus variedades

The authors reviewed 40 cases of endocardial cushion defect, 26 with the complete type and 14 incomplete. In 34 cases the diagnosis was corroborated anatomically and in the rest through angiocardiogram. 2. There is a discussion of proposed classifications and in accordance with the abnormality of the endocardial cushions, they outline the anatomic varieties. 3. They show that the complete and partial forms have notable differences in their clinical picture and in the prognosis. Particularly when there are associated malformations. They also give a detailed account of the essential data for the differential diagnosis. 4. In those cases with the partial type, the electrocardiogram showed typical behavior, whereas, in those with complete type the results were related to the associated malformations. 5. The anatomy of the persistence of endocardial cushion defect is analyzed and taking this into consideration, the problems which occur with mitral valve replacement are discussed. 6. They emphasize the importance of an excellent angiographic study, which besides its diagnostic value, is fundamental in making a decision in regard to surgical selection and technique. 7. They show the high frequency of malformations which may coexist with Endocardial cushion defect and remind us that as long as we continue to wait for classic data, especially of tb electrocardiogram, and ignore the left ventriculogram to establish the diagnosis, an important number of cases will remain undiagnosed. 8. They show that in the incomplete type there habitually exits situs solitus and the associated malformations are rare and simple; on the other hand in the complete, situs ambiguo was proven in 69.2% and solitus in the rest, and in 92.3% there were complex associated malformations. They affirm that with the suspicion or the confirmation of the complete type consider the possibility of it is imperative to heterotaxia. If this exist and there is low pulmonary flow we should suspect the coexistence with tetralogy of Fallot.

[Atrioventricular conduction disorders following total correction of tetralogy of Fallot. Analysis of the electrogram of the bundle of His]. / Trastornos de conducción auriculoventricular post-corrección total de la tetralogía de Fallot. Análisis mediante el electrograma del haz de His

A study was made of the electric activity of the atrioventricular (AV) conduction system in basal conditions and with atrial stimulation in order to discover the type, severity and prognosis of the AV disturbance in cases of total correction of tetralogy of Fallot. The authors studied thirteen patients from the Paediatric Department of the National Institute of Cardiology who had undergone such surgery, 7 males, 6 females from 3 to 22 years old. All presented advanced RBBB and sinus rhythm; in the immediate postoperative period, one presented complete transitory A-V block which required a stand by pacemaker; in 2 cases there was a first degree AV block; in two other, LAH and LPH. In 5 cases atrial stimulation was made with single charges and progressive frequency. Measurements were taken at the customary intervals. In basal conditions, prolongation of the AH interval was only found in 2 patients, both with first degree AV block in the peripheral EKG; both patients were taking digitalis. The HV interval was longer than normal in 3 cases, with one of these showing also a lengthened AH interval. The atrial stimulation showed prolonged ventricular activation in 2 cases, one of them with normal basal HV interval. The authors conclude that this procedure permits: 1) The discovery of alterations in the AV conduction system which could not be found in a peripheral EKG. 2) Localization of the site of the lesion. 3) The finding of disturbances of the ventricular conduction by atrial stimulation. 4) Identification of those patients who, after a complete correction of tetralogy of Fallot, show a potential high risk of developing complete complete AV block or of sudden death. 5) The establishment of a real prognosis in these patients.

[Diagnostic problems in visceral heterotaxia]. / Problemas diagnósticos en heterotaxia visceral

Due to the lack of uniformity in the criteria for formulating the diagnosis of the syndrome of heterotaxy, 12 cases with this abnormality were reviewed. The patients were selected on the following basis: symmetrical liver, changeable P waves in consecutive electrocardiograms, bronchial isomerism, hematological disturbances, anomalous relationship of the inferior vena cava and abdominal aorta, anomalous systemic and pulmonary venous drainage and complex cardiac malformations. The most frequent findings were: symmetrical liver, changeable P waves, anomalous systemic venous return, anomalies of the atrio-ventricular valves, particularly atrioventricular canal, aorto-cava juxtaposition, single atrium, anomalous pulmonary venous return, transposition of the great arteries and pulmonary stenosis. Less frequent anomalies were: atrial and ventricular septal defects, atrial isomerism, truncus arteriosus and partial distortion of the great arteries. The hematological disturbances as well as the radioisotope scanning of the liver and the spleen were of little help. Suggestions are given for the diagnosis of the syndrome and for the evaluation of present diagnostic procedures making necessary to use the data gathered with more precision.

[Hemodynamics changes in children and adolescents with mitral valve replacement]. / Cambios hemodinámicos en niños y adolescentes con reemplazo valvular mitral

The authors analyze the pre and post-operative hemodynamic picture of 30 children and adolescents with mitral valve replacement, which corresponds to a group of 106 patients operated on from 1964 to 1974. At variable time periods, between 9 days and 48 months (average 28 months) from the valve replacement, a new catheterization was done. The majority of the studies were done in the period between 13 and 36 months. Of the 30 cases, 21 were carriers of the Starr-Edwards valve, and the rest of different types. The Starr-Edwards valves produced a lawering of the CVP from 23.0 to 11.0 mm. Hg (average values) whereas with the other types the average pre-operative figure was 21.0 and in the post-operative period it fell to 11.0 mm. Hg. In the group with SE valves, pre-operative SPP was an average of 64.3 and in the post-operative period it was 32.0 mm. Hg. In the cases of SE valves the pre-operative total pulmonary resistances were 12.3 units and post-operatively they fell to 3.7 units. With the other types of valves the pre-opeative average was 10.9 units and post-operatively it was 5.3 units. The hemodynamic results obtained over a period of time with valvular substitution were similar in the distinct types of valves. However in the SE the benefits resulted more constant. The value of radiological and electrocardiographic study in order to predict the early post-operative hemodynamic changes is discussed. These studies serve essentially for a long range evaluation, whereas the hemodynamic, and clinical improvement maintained a strict relationship. This work shows that, in children and adolescents, the presence of severe venous-capillary and arterial pulmonary hypertension, and the elevated pulmonary resistences, are not contraindications for surgical treatment. It equally proves the eficacy of the valvular replacement, when the surgical indication and the control of the patients are handled in the proper way.

[Importance of the systemicopulmonary collateral arterial circulation in congenital cardiopathies]. / Importancia de la circulación arterial colateral sistemicopulmonar en cardiopatías congenitas.

This paper manifests the importance of the systemic-pulmonary collateral circulation in congenital heart diseases. It shows that through the angiographic and hemodynamic study you should recognize the number, origin, course, and size of each of these arteries because during the corrective surgical treatment of certain types of heart diseases, these arteries should be tied off to prevent cardiac overload during the procedure and to prevent intrapulmonary short circuits from left to right in the postoperative period. The knowledge of the central and peripheral pulmonary arteries is important and because of this it should be remembered that the area of the section of the pulmonary arteries, right to left, together should be at least the equivalent of half of the area of the section of the aorta in its diaphragmatic level, the diameter which permits an acceptable cardiac output after the intervention. If the arteries are adequate a plan of surgical intervention which permits the control of the collateral systemic-pulmonary great arteries should be drawn up.

[Aneurysm of the membranous portion of the interventricular septum]. / Aneurisma de la porción membranosa del tabique interventricular

The membranous portion of the interventricular septum represents the final phase of the ventricular growth. It is situated between the orifice of the coronary sinus and the supraventricular crest; immediately below the right aortic semilunar valves and not the coronary. Four cases of aneurism of the membranous portion of the interventricular septum are presented; in two, the diagnosis was made by angiocardiography study and in the rest it was made with the findings of an autopsy. All were of the female sex. Two patients presented a systolic murmur in the low mesocardia; three had heart failure, two of which were secondary to an arteriovenous short circuit through an interventricular communication, and the other due to alternations in the automatism and in the atrioventricular circulation. One case had W-P-W, type A and during its evolution presented paroxysms of atrial fibrillation and flutter, variable degrees of atrioventricular block with Stokes-Adams syndrome and ventricular fibrillation. In one case an obstruction at the level of the outflow tract of the right ventricle was suspected through phonocardiographic studies, and was confirmed subsequently with hemodynamic study. This same case presented a protosystolic aortic snap, at 0.13-0.14 sec. of the q wave of the electrocardiogram, described as of value for the diagnosis of this malformation. In two cases the angiocardiographic study showed the presence of the aneurism in the membranous portion of the interventricular septum, in one, it was visualized in the posterioanterior projection and in another in the lateral. One of the specimens had the aneurism adhered to the tricuspid septal valve, and also a fissure which communicated the left ventricle with the right atrium. In the other, the aneurismal sac was located below the septal valve of the tricuspid, producing a distortion in the anatomical architecture of the atrioventricular orifice.

[Tricuspid atresia: A therapeutic problem]. / Atresia tricúspidea: un problema terapéutico

1. The authors present 80 cases of tricuspid atresia of the Children's Cardiology Service of the Instituto Nacional de Cardiología de México. They propose their own classification based on the position of the visceral suits and of the great arteries and the possible existance of a persistent truncus arteriosus. 2. The requirements that should be fulfiled to establish an anatomic and hemodynamic diagnosis are determined; and the need to know in detail the anatomy of the right ventricle; of its exit chamber, of the pulmonary valve and of the pulmonary truncus is emphasized; as well as the measures in the auricles and the left ventricle. 3. They insist upon the need, when the pulmonar arterial pressure cannot be measured directly, to introduce a catheter in a pulmonar vein, because the pressures obtained are quite similar to the pressure in the pulmonar arterial territory. 4. The fundamental data of the anatomic and hemodynamic study are discussed and illustrated. They confirm the close relation that exists between the diameter of the exit chamber of the right ventricle and of the valvular ring, the pulmonary truncus and its branches. 5. In all cases of tricuspid atresia with AQRS deviated to the right and downwards in the frontal plane; transposition of the great arteries should be thought of when it deviates to the left and upwards, in patients with crossed great arteries. 6. In the cases operated with sistemic-pulmonary fistula, there was an intrahospital mortality range of 25%, similar to that obtained by most authors. 7. The paliative surgical procedures are analyzed, and those that at present could be considered as "corrective" such as Fontan and Kreutzer's operations. The need, to gather several diagnostic parameters. To establish the surgical indication in the sistemicpulmonary and venus shunts, is emphasized.

[Stable fibrous subaortic stenosis]. / Estenosis subaoortica fibrosa fija

The authors studied 37 patients belonging to the Pediatric Cardiology Service of the Institute National of Cardiology who were carriers of fixed fibrinous subaortic stenosis. The diagnosis was established by surgery or autopsy. Isolated subvalvular obstruction was found in 24 patients (63%), which represents the most important number of cases in the literature. The analysis of the 24 cases permitted important conclusions: 1. All the patients had systolic thrills in the suprasternal hollow and carotidinous pathways. 2. No case had protosystolic click. In all, the murmur's epicenter was in the 3rd and 4th IIS in the parasternal line, a fact which can lead to a mistaken diagnosis of interventricular septal defect. 66.6% of the patients had a diastolic murmur heard in the aortic focus, a secondary accompaniement to secondary valvular aortic insufficiency. The intensity of the second aortic sound held an inverse relationship to the magnitude of the gradient. The presence of paradoxic splitting of the second heart sound as well as prolongation of the expulsion period in the carotidogram are indexes for the severity of the obstruction. 3. A relationship between the severity of the lesion and the dilatation of the left atrium was found. The cardiomegaly had no relationship to the severity of the obstruction with the increase in ventricular telediastolic pressure or to the evolution time. 4. An adequate hemodynamic study permits evaluating and locating the site of the obstruction. Likewise, precise ventriculography appraises the nature of the narrowing. 5. Aortic regurgitation is located at the valvular level. Aortography permits its affirmation. Probably the stream coming from subvalvular stenosis produces fibrosis or asynchronism in the closing of the aortic valves. 6. Surgical treatment offers excelent perspectives in mortality as well as reducing the gradient. None of our patients operated on had hospital or later death. 7. Postoperatory evaluation was performed on six patients, and by means of measuring the gradient between the left ventricle and the aorta, the good surgical results could be demonstrated. 8. The natural evolution of patients with fixed fibrous subaortic stenosis is similar to that of other forms of congenital aortic stenosis. Taking into consideration this concept, and before the low risk (0%) in this type of surgery, this is the treatment of choice.