Repair of primary or complicated aortic coarctation in the adult with cardiopulmonary bypass and hypothermic circulatory arrest.

OBJECTIVE: Patients with primary aortic coarctation or complications of a previous coarctation repair may seek treatment as adults. Management options include open, endovascular, hybrid, and extra-anatomic repairs. We evaluated the results of open direct repair with total cardiopulmonary bypass and hypothermic circulatory arrest. METHODS: Twenty-seven patients with primary coarctation with or without associated aortic abnormalities or with complications of a previous coarctation repair were treated during a 20-year interval. Mean age was 37 years (range, 15-71 years). Thirteen patients had primary coarctation (7 with associated aneurysms), 3 patients had aneurysms of the aorta above or below a noncritical narrowing of the aorta at the isthmus ("pseudocoarctation"), and 11 patients had previous repair of a coarctation. The previous repairs were bypass grafting of the coarctation (n = 5), interposition grafting (n = 3), patch angioplasty (n = 2), and primary repair (n = 1). RESULTS: Mean durations of cardiopulmonary bypass, hypothermic circulatory arrest and hypothermic fibrillation were 104, 36, and 76 minutes, respectively. There were no in-hospital deaths, and no patients sustained stroke, spinal cord ischemic injury, or renal or respiratory failure. Thirteen patients received no blood products. No patient has had evidence of recurrent coarctation or aneurysm formation. CONCLUSIONS: Cardiopulmonary bypass with hypothermic circulatory arrest is a safe and suitable technique for treatment of primary and recurrent coarctation. It is associated with low operative risk and absence of major complications.

Traumatic diaphragmatic injuries.

Although numerous articles have been written over the past two decades with regard to the treatment of traumatic diaphragmatic hernia, little has actually changed during that time. The ability to make the diagnosis has somewhat improved because of the technologic advances in CT; however, it remains true that the best tool to guide the clinician toward the appropriate diagnosis is a high index of suspicion in patients with blunt or appropriate penetrating trauma. Although laparoscopic or thoracoscopic management of such patients may become prevalent with increasing experience, at present the open approach and simple repair remain the mainstays of management. The patient's survival still depends more on the severity of concomitant nondiaphragmatic injuries and in many cases the diaphragmatic laceration is the least worrisome and least morbid of the patient's injuries. Operative repair results in a good outcome in most patients in the absence of other serious injuries.

Ischemic colitis: spectrum of disease and outcome.

BACKGROUND: The aim of this study was to identify risk factors, clinical characteristics, and outcome of patients with colon ischemia. METHODS: A 10-year (1992-2002) retrospective study was undertaken. Patients were identified from computerized hospital discharge information. Patient variables were entered into a computerized database and analyzed. RESULTS: One hundred twenty-nine patients were identified. The mean age was 66 years (range, 29-98 years); 47% were male. Forty-three patients (33%) had chronic renal failure; 73 patients (57%) were receiving vasoactive drugs, and 72 patients (56%) had atherosclerosis. Fifty-four of 129 patients (42%) had ischemic colitis in-hospital. Fifty-six of 129 patients (43%) had melena; 49 of 56 patients (88%) survived. Forty-three of 129 patients (33%) had an acute abdomen; 22 of 43 patients (51%) died. Seventy of 129 patients (54%) were treated nonoperatively initially; the condition of 17 of 70 patients (24%) required surgery. Of 76 patients who were treated operatively, 31 patients (41%) died. Eleven patients at operation had ischemia without colon infarction or perforation; 5 of these patients (45%) died. The overall mortality rate was 29% (37/129 patients). CONCLUSION: Ischemic colitis is associated with chronic renal failure and atherosclerosis. Patients commonly have an acute abdomen. The absence of colonic infarction does not ensure a favorable outcome. Patients who are felt to be candidates for nonoperative therapy have significant mortality rates. Mortality rates remain high, despite treatment.