Complications and Risk Assessment of 25 Years in Pediatric Pacing.

BACKGROUND: Children who require cardiac pacemaker implantation have presented a small patient sub-population since the breakthrough of this technology in the 1950s and 1960s. Their small bodies result in a technical challenge for the operating surgeon and put the patient at risk for a series of specific complications. Our study aims to analyze complications and to identify risk factors of endocardial and epicardial pacemaker systems in children. METHODS: All pacemaker-related operations in pediatric patients up to the age of 18 years from 1985 through 2010 were retrospectively evaluated. Demographic data including age, height, and weight were recorded. Idiopathic and postoperative dysrhythmias were analyzed separately. RESULTS: A total of 149 pacemaker operations were performed in 73 patients. Thirty-two patients did not have a previous cardiac operation. Indications for revision included box exchange, lead-related problems, pacemaker pocket complications, impaired left ventricular function, and pectoral muscle stimulation. Increased pacing thresholds occurred in 17.2% of the patients with epicardial leads compared with 2.9% in the endocardial group. Aside from threshold-related revision, lead problems are more common in the endocardial group (30.4% vs 17.2%). Venous thrombosis occurred in 13.7% of the patients (only endocardial), preferentially (25%) in the weight group less than 15 kg and in idiopathic patients (15.6% vs 10.5% with prior cardiac surgery). CONCLUSIONS: Cardiac pacing is particularly challenging in the pediatric patient population facing a large number of reoperations during their lifetime. The lack of clear superiority of either epicardial or endocardial pacing systems requires an individual concept.

Stricture Rate after Laparoscopic Roux-en-Y Gastric Bypass with a 21-mm Circular Stapler versus a 25-mm Linear Stapler.

Background: Obesity is estimated to affect more than one and a half billion adults. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become one of the preferred weight loss procedures. However, complications can occur. Strictures at the gastrojejunal anastomosis lead to clinical symptoms such as vomiting, dysphagia, and patient discomfort. The stricture rate has been correlated with the size and type of stapler used. Methods: A retrospective review of the clinical records of patients who underwent LRYGB was performed between 2003 and 2010. A comparison was made between a 21-mm circular stapler technique and a 25-mm linear stapler technique. Results: The stricture rate for the 21-mm circular stapler group was 7.12% and comparable to the national average. Using the 25-mm linear stapler, this complication rate significantly decreased to 1.09% (p<0.0004; odds ratio 6.5; [95% confidence interval 1.96-33.83]). Conclusions: Stricture after LRYGB is a serious complication. This study found that with a change in technique, this complication can be decreased considerably.

The efficacy of prophylactic IVC filters in gastric bypass surgery.

BACKGROUND: Patients undergoing gastric bypass surgery have a high risk for thromboembolic events. Over the last decade, the use of prophylactic IVC filters (IVCF) has drastically increased for patients who are considered high risk. However, the role and efficacy of prophylactic IVCF placement remain controversial, and the literature is limited to a few retrospective studies. METHODS: We conducted a systematic review of the literature. A total of 21 articles were analyzed, and eight relevant retrospective studies were chosen for review of data. Data from laparoscopic gastric bypass surgery were compared to open gastric bypass surgery RESULTS: The relevant eight retrospective studies included a total of 597 patients. Patients had IVCFs before laparoscopic gastric bypass (41 %) and before open gastric bypass (59 %). There were 5 postoperative pulmonary emboli (PE) (0.84 %), 21 DVTs (3.52 %), 5 minor IVCF-related complications (0.84 %), 2 major IVCF-related complications (0.34 %), and 10 deaths (1.68 %). The rate of postoperative PE was the same in the laparoscopic group and the open group (0.84 %). The rate of DVT in the laparoscopic group was 5.02 %, and in the open group, it was 2.23 %. CONCLUSION: It is estimated that 55 % of bariatric surgeons use IVCF in high-risk patients. Prospective research that supports the use of IVCF is very limited, and individualized placement relies on retrospective studies only. In addition, patient characteristics associated with high risk vary between different studies. Our review showed that most of the published studies support the use of prophylactic IVCF and found it to be safe. On the other hand, the largest and most recent retrospective cohort study does not support their use. The efficacy of prophylactic IVCFs before gastric bypass surgery in high-risk patients has not been established.

The 100-year evolution of the isolated internal iliac artery aneurysm.

BACKGROUND: Isolated internal iliac artery aneurysms (IIIAA) are a rare form of aneurysm. The incidence increases with age, and the prevalence is higher in men. The clinical presentation can vary, and standard treatment protocols are not established. The first case of an IIIAA was described more than 100 years ago. The purpose of the study is to summarize the various clinical presentations and treatment options that have been reported in the literature in the past 100 years. METHODS: Literature about IIIAA was reviewed using the electronic databank PubMed. All case reports and case series were analyzed, and we included our own data with 2 case reports. RESULTS: Over time, IIIAA diagnosis increasingly resulted from asymptomatic incidental findings on radiologic studies. Various clinical presentations included abdominal pain, back pain, rectal bleeding, hydronephrosis with renal failure, hematuria, and free rupture with shock. Rupture has a mortality rate of 53%. IIIAAs were more common on the left (61.8% left, 27.3% right, 10.9% bilateral). Treatments include open surgical repair and endovascular repair using a variety of methods. One article reported a hybrid method using both endovascular and open surgical technique. CONCLUSIONS: Since its first description 100 years ago, we have gained knowledge about the natural history of IIIAA. Multiple treatment options have been described, but long-term outcome needs further investigation.