Prosthetic Aortic Valve Fixation Study: 48 Replacement Valves Analyzed Using Digital Pressure Mapping.

OBJECTIVE: Prostheses attachment is critical in aortic valve replacement surgery, yet reliable prosthetic security remains a challenge. Accurate techniques to analyze prosthetic fixation pressures may enable the use of fewer sutures while reducing the risk of paravalvular leaks (PVL). METHODS: Customized digital thin film pressure transducers were sutured between aortic annulus models and 21-mm bioprosthetic valves with 15 × 4-mm, 12 × 4-mm, or 9 × 6-mm-wide pledgeted mattress sutures. Simulating open and minimally invasive access, 4 surgeons, blinded to data acquisition, each secured 12 valves using manual knot-tying (hand-tied [HT] or knot-pusher [KP]) or automated titanium fasteners (TFs). Real-time pressure measurements and times were recorded. Two-dimensional (2D) and 3D pressure maps were generated for all valves. Pressures less than 80 mm Hg were considered at risk for PVL. RESULTS: Pressures under each knot (intrasuture) fell less than 80 mm Hg for 12 of 144 manual knots (5/144 HT, 7/144 KP) versus 0 of 288 TF (P < 0.001). Pressures outside adjacent sutures (extrasuture) were less than 80 mm Hg in 10 of 60 HT, zero of 60 KP, and zero of 120 TF sites for 15 × 4-mm valves; 17 of 48 HT, 25 of 48 KP, and 12 of 96 TF for 12 × 4-mm valves; and 15 of 36 HT, 17 of 36 KP, and 9 and 72 TF for 9 × 6-mm valves; P < 0.001 all manual versus TF. Annular areas with pressures less than 80 mm Hg ranged from 0% of the sewing-ring area (all open TF) to 31% (12 × 4 mm, KP). The average time per manual knot, 46 seconds (HT, 31 seconds; KP, 61 seconds), was greater than TF, 14 seconds (P < 0.005). CONCLUSIONS: Reduced operative times and PVL risk would fortify the advantages of surgical aortic valve replacement. This research encourages continued exploration of technical factors in optimizing prosthetic valve security.

Evaluation and treatment of pump thrombosis and hemolysis.

Ventricular assist devices (VADs) are not fully biocompatible, and are therefore predisposed to device thrombosis and subsequent pump dysfunction. Clinically significant hemolysis in VADs most often occurs as a result of device thrombosis, but can also be caused by other factors. Herein we describe the evaluation and management of VAD thrombosis and hemolysis.

Feasibility and analgesic efficacy of the transversus abdominis plane block after single-port laparoscopy in patients having bariatric surgery.

PURPOSE: The transversus abdominis plane (TAP) block is a technique increasingly used for analgesia after surgery on the anterior abdominal wall. We undertook this study to determine the feasibility and analgesic efficacy of ultrasound-guided TAP blocks in morbidly obese patients. We describe the dermatomal spread of local anesthetic in TAP blocks administered, and test the hypothesis that TAP blocks decrease visual analog scale (VAS) scores. PATIENTS AND METHODS: After ethics committee approval and informed consent, 35 patients with body mass index >35 undergoing single-port sleeve gastrectomy (SPSG) were enrolled. All patients received balanced general anesthesia, followed by intravenous patient-controlled analgesia (IV-PCA; hydromorphone) postoperatively; all reported VAS >3 upon arrival to the recovery room. From the cohort of 35 patients having single-port laparoscopy (SPL), a sealed envelope method was used to randomly select ten patients to the TAP group and 25 patients to the control group. The ten patients in the TAP group received ultrasound-guided TAP blocks with 30 mL of 0.2% Ropivacaine injected bilaterally. The dermatomal distribution of the sensory block (by pinprick test) was recorded. VAS scores for the first 24 hours after surgery and opioid use were compared between the IV-PCA+TAP block and IV-PCA only groups. RESULTS: Sensory block ranged from T5-L1. Mean VAS pain scores decreased from 8 ± 2 to 4 ± 3 (P=0.04) within 30 minutes of TAP block administration. Compared with patients given IV-PCA only, significantly fewer patients who received TAP block had moderate or severe pain (VAS 4-10) after block administration at 6 hours and 12 hours post-surgery. However, cumulative consumption of hydromorphone at 24 hours after SPSG surgery was similar for both groups. CONCLUSION: Ultrasound-guided TAP blocks in morbidly obese patients are feasible and result in satisfactory analgesia following SPSG in the immediate postoperative period.

The consequence of undertreatment of patients treated with breast conserving therapy for ductal carcinoma in-situ.

BACKGROUND: The use of clinical features to allocate adjuvant therapy in the treatment of ductal carcinoma in situ with breast-conserving therapy remains controversial. METHODS: A review of patients with ductal carcinoma in situ treated with breast-conserving therapy was performed. The recurrence rate was examined in relation to patient age, tumor characteristics, Van Nuys Prognostic Index, and the receipt of prescribed adjuvant therapies. RESULTS: Six percent of patients (17 of 294) had developed local recurrences after a median follow-up period of 63 months. Fifty-nine percent of patients (91 of 154) with estrogen receptor-positive tumors did not receive prescribed tamoxifen. Thirty-one percent of patients (45 of 147) with Van Nuys Prognostic Index scores ≥7 did not receive recommended radiation therapy. Receipt of prescribed adjuvant therapy did not result in a decrease in the rate of local recurrence. Patient age was the only factor associated with local recurrence on univariate but not on multivariate analysis (P = .374). CONCLUSIONS: A low rate of local recurrence was achieved despite a large number of patients' not receiving prescribed adjuvant therapies.

The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy.

INTRODUCTION: Single-port laparoscopy (SPL) employs a 1.5- to 2.5-cm incision at the umbilicus for the placement of a single working port. We hypothesized that the longer incision created by SPL compared with multiport laparoscopy may increase the incidence of trocar-site hernias. We examined our experience with SPL in bariatric operations. METHODS: There were 734 laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding procedures performed at our institution between 2001 and 2011. Fifty-eight patients were lost to follow-up or had a short duration of follow-up (<1 month). Of the remaining 676 cases, 163 were performed via SPL. All laparoscopic wounds created by trocar size greater than 12 mm were closed with absorbable suture. RESULTS: Patient demographics of the SPL group and the multiport group were similar in terms of age, gender, and comorbidities. The average body mass index (BMI) of the SPL group was lower than the multiport group (43.5 ± 5.3 vs. 45.8 ± 7.7, p < 0.01). The mean follow-up for the SPL group was 11 months versus 24 months for the multiport group. There were three trocar-site hernias out of 513 cases in the multiport compared to one hernia out of 163 cases in the SPL group (0.6 vs. 0.6 %, p = 0.967). All trocar-site hernias occurred at the 15-mm port site. The median time to hernia occurrence for the multiport group was 13 months (range, 1-18). In the SPL group, the hernia occurred at 8 months. On multivariate analysis, age, BMI, SPL, procedure type, and the postoperative weight loss were not associated with the development of trocar-site hernias. CONCLUSIONS: SPL did not increase the rate of trocar-site hernia in this series. A low rate of trocar-site hernia can be achieved with the use of SPL in bariatric surgery.

Surgical residents' perception of the 16-hour work day restriction: concern for negative impact on resident education and patient care.

BACKGROUND: Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-hour duty period limitation for postgraduate year I (PGY I) residents. Our aim was to assess the attitudes and perception of general surgery residents regarding the new duty hour limitation as well as the transfer of care process under the new guidelines. STUDY DESIGN: An anonymous, web-based survey was conducted nationally 7 months after the institution of the 16-hour duty limitation. RESULTS: A total of 464 completed surveys were analyzed. Overall, 75% of residents expressed dissatisfaction with the new duty hour limitation. PGY II to V residents reported a higher level of dissatisfaction compared with PGY I residents (87% vs 54%, p < 0.01). Eighty-nine percent of PGY II to V residents responded that there has been a shift of responsibilities from the PGY I class to PGY II to V residents, with 73% reporting increased fatigue as a result. Seventy-five percent of PGY I and 94% of PGY II to V residents expressed concerns about the adverse impact of the restrictions on the education of PGY I residents (p < 0.01). Residents at all PGY training levels reported encountering problems due to inadequate sign-outs (PGY I, 59%; PGY II to V, 85%; p < 0.01). Sixty-two percent of PGY I residents and 54% of PGY II to V residents believed that the new 16-hour duty restriction contributes to inadequate sign-outs (p = NS). Most PGY II to V residents (86%) believe there is a decreased level of patient ownership due to the work hour restrictions. CONCLUSIONS: The results of the survey suggest that the majority of general surgery residents are concerned over the potential negative impact of the duty limitation on resident education and patient care. Further research is needed to address these concerns.

Role of mitral valve plication in the surgical management of hypertrophic cardiomyopathy.

BACKGROUND: We have previously reported our 3-step repair for obstructive hypertrophic cardiomyopathy (HCM) consisting of resection of the septum, horizontal plication of the anterior mitral leaflet (AML), and release of abnormal papillary muscle attachments. This article reviews our complete experience with surgical management of HCM to better understand the role and relevance of mitral plication. METHODS: From 1997 to 2011, 132 patients with HCM underwent surgical treatment at our institution. Eighty-two patients (62%) received AML plication based on selection criteria and were classified as group A; patients in group B did not receive plication. All patients underwent preoperative and postoperative echocardiography. Long-term clinical follow-up was obtained by review of scheduled echocardiograms and direct patient interview. RESULTS: The average age of all patients was 55.5 years. Operative mortality was 0%. The mean left ventricular outflow tract (LVOT) gradient decreased from 118±41 mm Hg to 6±13 mm Hg (p<0.0001). Mean mitral regurgitation improved from 2.4±1.0 to 0.5±0.7 (p<0.0001). Postoperatively, 96.2% of patients had no residual systolic anterior motion (SAM). Significant improvements in heart failure classification and quality of life scores were noted for all patients. Comparison of groups A and B showed no statistically significant differences in outcomes, complications, or survival. Survival at 1, 5, and 10 years was 98%, 98%, and 92%, respectively. CONCLUSIONS: The heterogeneity of the pathologic process in HCM supports detailed analysis of the septum, mitral leaflets, and subvalvular apparatus. Surgical management of HCM that includes horizontal plication of a lax and elongated AML is safe and results in durable clinical and echocardiographic improvement.

Outcomes of laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding in adolescents.

BACKGROUND: The goal of this study is to compare the outcomes of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese adolescents. METHODS: We performed a retrospective review of all adolescents between the ages of 15 and 19 who underwent LAGB or LRYGB at our university affiliated Bariatric Center of Excellence from 2002 to 2011. Postsurgical weight loss at 1, 3, 6, 12, 18, and 24 months was noted and expressed as percentage of excess weight loss (% EWL). RESULTS: Thirty-two patients underwent LRYGB and 23 underwent LAGB. The LAGB group was younger (18.6 ± 0.6 versus 17.2 ± 1.5) than the LRYGB group. Other preoperative demographic factors including body mass index, gender, ethnicity, and comorbidities were similar between the two groups. The average % EWL was superior in the LRYGB group compared to the LAGB group at all time points studied (p < 0.05), although at 2-year follow-up, only 16% (5/32) LRYGB and 30% (7/23) LAGB patients were available for follow-up. Three patients with type II diabetes mellitus underwent LRYGB and all experienced remission of their diabetes. The number of complications requiring interventions was similar between the two groups. CONCLUSIONS: In our study, adolescents undergoing LRYGB achieved superior weight loss compared to LAGB in the short-term follow-up. The complication rate for LAGB was similar compared to LRYGB. More studies are needed to monitor the long-term effects of these operations on adolescents before definitive recommendations can be made.

Does surgical relief of obstruction improve prognosis for hypertrophic cardiomyopathy?

Unique genetic characteristics of hypertrophic cardiomyopathy (HCM), including heterogeneity and incomplete penetrance, have made making predictions about prognosis complex. We reviewed data from septal myectomy results as published from 1980 to 2011, most of which come from specialized tertiary care centers. We also performed a retrospective review of 132 consecutive patients who underwent HCM surgery at our institution. At a mean follow-up of 4.2 ± 3.2 years (range, 3 days to 14.2 years), there were no deaths within 30 days of surgery for our cohort. Over the course of 15 years, 2 deaths occurred in older patients, both of whom had surgery for HCM along with additional cardiac procedures. Age, the presence of comorbidities, and concomitant cardiac procedures were not statistically significant risk factors for mortality. Overall survival at 1, 5, and 10 years was excellent: 99%, 99%, and 92%, respectively. Surgical myectomy has been proven to be a safe and effective procedure for symptomatic obstructive HCM, and it confers excellent survival similar to that of the healthy population.

Robotic-assisted resection of an intrapericardial bronchogenic cyst.

The advantages of robotic-assisted surgery have been well described and include improved three-dimensional visualization, increased precision of dissection, and the absence of tremor. These characteristics are particularly useful in the mediastinal dissection of major vascular structures. We present a case of an intrapericardial bronchogenic cyst resected with robotic assistance. Bronchogenic cysts are congenital thoracic anomalies that typically occur in the mediastinum or lung parenchyma, and occasionally within the pericardium. Historically a sternotomy was required for complete resection, although a thoracoscopic approach has now been widely adopted. We report the resection of an intrapericardial bronchogenic cyst utilizing a robotic-assisted thoracoscopic approach and a review of the literature regarding the incidence, diagnosis, and management of this rare condition.