Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE

swissknife spezial 06 12.06.2006 13:39 Uhr Seite 53
Off-pump extraanatomic aortic bypass for the treatment of complex aortic coarctation and
hypoplastic aortic arch
Objective: Despite advantages in management of patients with severe (re-) coartation and
hypoplastic aortic arch, the definite surgical strategy is still issue of ongoing debate. Local
repair often enough requires extensive dissecting, cardiopulmonary bypass and deep-hypothermic-circulatory-arrest
(DHCA) and is associated with a high incidence of perioperative
complications. Orthotopic ascending-to-descending aortic bypass is a favourable option and
superior to local repair for this patient population but prone to failure due to graft-tension in the
growing child. Aim of this study was to determine the short- and medium-term outcome of offpump
extraanatomic aortic bypass in patients with complex aortic (re-) coarctation.
Methods: From 02/2000 to 12/2005 11 consecutive patients (median age 20 years, range
11-38 years) with severe aortic (re-) coarctation (n=4) or hypoplastic aortic arch (n=7) underwent
extraanatomic aortic bypass through median sternotomy. All but 3 patients had undergone
previous surgery at least one time using resection and end-to-end anastomosis, subclavian
flap or patch aortoplasty or interposition of a polyester tube graft. Two patients had a
history of angioplasty and stenting. One patient additionally received a bypass from the
ascending aorta to the common carotid artery (ACC) with transposition of the subclavian
artery to the ACC. Three patients additionally underwent replacement of the ascending aorta
due to large aneurysms using cardiopulmonary bypass.
Results: Postoperative hospital course was uneventful in all patients. There was no case of
spinal cord ischemia. Perioperative mortality was zero. Follow-up was performed using twodimensional
echocardiography and magnetic-resonance imaging when appropriate. During
a mean follow-up period of 34 ± 22 months, no patient needed redo-surgery or intervention
for recoarctation. There was no case of pseudoaneurysm formation in the patient population.
Conclusion: Extraanatomic aortic bypass is an excellent treatment modality for complex aortic
coarctation and hypoplastic aortic arch especially in patients with concomitant cardiac
diseases and a history of surgery on the thoracic aorta. Avoidance of cardiopulmonary
bypass, re-thoracotomy and extensive dissecting diminishes perioperative risk and improves
postoperative outcome compared to orthotopic aortic bypass or local repair.
32.08
K. Djebaili 1 , C. Tissot 2 , Y. Aggoun 3 , E. DaCruz 4 , M. Beghetti 3 , R. Corbelli 3 , J. Sierra 5 , A. Kalangos 6
1 Cardiovascular Surgery Unit, Geneva University Hospital, 1211 Geneva/CH, 2 Paediatric
Cardiology Unit, University Hospital of Geneva, 1211 Geneva/CH, 3 Paediatric Cardiology Unit,
HUG, 1211 Geneva/CH, 4 Paediatric Cardiology Unit, HUG, 1211 Geneva/CH, 5 Department of
Cardiovascular Surgery, University Hospital of Geneva, 1211 Geneva/CH, 6 Cardiovascular
Surgery, University Hospital of Geneva, 1211 Geneva/CH
Lecompte manoeuvre as an alternative to pulmonary artery plication in surgical repair of pulmonary
valve agenesia
Objective: Pulmonary valve agenesia is a rare congenital cardiopathy associated with aneurysmal
dilatation of the pulmonary arteries and respiratory compromise. We report successful
impact on the respiratory tract of surgical repair including a Lecompte manoeuvre, instead
of plication of the pulmonary arteries.
Methods: Two patients, aged 6 and 10 months, were operated in 2005 at our institution for
pulmonary valve agenesia with interventricular septal defect and aneurysmal pulmonary
arteries dilatation. They presented with significant preoperative obstructive respiratory symptoms
due to compression of the bronchial tree by the aneurysmal pulmonary arteries. The
pre-operative bronchoscopy showed pulsatile compression of some area of the bronchial
tree, in relation to the dilated pulmonary vessels and aortic arch. The chest CT-scan showed
some degree of emphysema in the area where the bronchial obstruction was present.
Surgical repair consisted of interventricular septal defect closure by a pericardial patch and
anastomosis of a valvulated Contegra tube between the right ventricule and the pulmonary
bifurcation. The Lecompte manoeuvre was performed in order to reduce the diameter of the
pulmonary arteries by a stretching mechanism. It was achieved by transverse section of the
ascending aorta and dissection of the pulmonary arteries, allowing to mobilize and place the
pulmonary bifurcation in an anterior position to the aorta.
Results: The immediate post-operative bronchoscopy and chest CT-scan showed persistent
but significantly decreased compression of the bronchial tree. The two patients were extubated
without respiratory symptoms. The clinical outcome was excellent without any residual
obstructive respiratory symptoms.
Conclusion: In our small experience, surgical repair of pulmonary valve agenesia and
Paediatric Cardiology Unit Paediatric Cardiology Unit Paediatric Cardiology Unit aneurysmal
dilatation of the pulmonary arteries including a Lecompte manoeuvre may be an alternative
to pulmonary artery plication. By changing the mediastinal geometry and the relationship between
the great vessels and the bronchial tree, it has a favourable impact on the respiratory
tract compressions. The clinical outcome is good with no residual respiratory symptoms.
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33.01
R. Rosso 1 , B. Roche 2 , P.A. Stalder 3 , A. Kuhrmeier 4
1 Vascular Surgery, Ospedale Regionale Lugano, Lugano/CH, 2 Unité De Proctologie, Hôpitaux
Universitaires de Genève, 1200 Genève/CH, 3 Vascular Surgery, Ospedale Regionale Lugano,
6900 Lugano/CH, 4 General Surgery, Ospedale Regionale Lugano, Lugano/CH
Soave’s procedure: the final sphincter saving solution for iatrogenic rectal lesions
Objective: Restoring intestinal continuity following low colorectal anastomotic complications
or low Hartmann’s procedure can be associates with difficult and dangerous pelvic dissection.
Soave's Procedure, which consists of a transrectal coloanal sleeve anastomosis, without
the need for potential hazardous perirectal dissection, may provide an opportunity to restore
continuity, the alternative being a definitive colostomy. We report two cases and a review of
the literature.
Methods: A 52 year old woman, otherwise healthy, with a rectal adenocarcinoma was submitted
to a laparoscopic low anterior resection with TME. She developed a necrosis of the descending
colon and had to be reoperated, a Hartmann’s procedure was then performed. Four
months later we reoperated the patient, planning to restore the intestinal continuity. In the presence
of a very short rectal stump and severe fibrosis with adherence to the sacrum and to
the vagina, we performed a Soave’s procedure protected by a temporary loop ileostomy.
There were neither intraoperative nor postoperative complications and we closed the ileostomy
6 weeks later with a good functional result at a three month follow-up. A 75 year old
woman with a rectal adenocarcinoma and preoperative radiotherapy was submitted to a low
anterior resection and TME. Postoperatively she developed a recto-vaginal fistula and was
then reoperated, a loop ileostomy being performed. Two attempts to close the fistula with
advanced rectal flaps were unsuccessful. One year later we performed the Soaves’s procedure
without complications and 8 weeks later the ileostomy was closed. At a follow-up more
than one year later, the patient had an excellent functional result without recurrence of the rectovaginal
fistula.
Results: Our results confirm the low morbidity of the procedure and the satisfactory functional
results described in the literature.
Conclusion: Rectal conditions such as severe irradiation injury, low colorectal anastomotic
fistula and low Hartmann’s procedures are characterized by inflamed and fibrosed pelvis,
that renders perirectal dissection difficult and hazardous. Soave’s procedure obviates the
need for extensive pelvic dissection, providing good technical and functional results.
33.02
S. Breitenstein1 , A. Kraus2 , D. Hahnloser3 , M. Decurtins4 , P. Clavien5 , N. Demartines2 1Department of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich/
CH, 2Dept. of Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH,
3 4 Viszeralchirurgie Und Transplantation, Universitätsspital, 8091 Zürich/CH, Chirurgische
Klinik, Kantonsspital, 8401 Winterthur/CH, 5Swiss Hpb Center, Dept. Visceral and Transplant
Surgery, University Hospital of Zurich, 8091 Zurich/CH
Emergency left colon resection for acute perforation. Primary anastomosis or Hartmann’s
procedure? A case-matched control study
Objective: Colon perforation is associated with considerable mortality and morbidity, and the
optimal surgical treatment strategy remains controversial. The aim of this study is to compare
the effectiveness and safety of primary anastomosis vs. Hartmann’s operation (HP) in
patients with acute left-sided colon perforation.
Methods: 30 consecutive patients operated between January 2000 and July 2005 with primary
anastomosis and protective ileostomy (PAS) were matched one by one to 30 HP
patients controlling for age, gender, ASA, BMI and peritonitis severity (Hinchey). Furthermore,
PAS patients were matched to patients with primary anastomosis without ileostomy (PA).
Endpoints of the study were mortality, morbidity and stoma reversal rates.
Results: Hospital mortality was observed only during the resection-operation and was similar
between HP (17%) and PAS (10%) patients (p=0.69). Frequency and severity of complications
(requiring re-intervention or ICU) were also comparable for the first operation (60% vs.
56% and 30% vs. 32%, respectively). Stoma reversal rate was higher in PAS patients compared
to HP patients (96% vs. 60%, p=0.001), and associated with significantly less complications
(23% vs. 66%, p=0.02), with lower severity of complications (7% vs. 33%, p=0.02).
Overall mean operation time (resection plus reversal) was comparable between the groups:
355 vs. 395 min, (p=0.09). 17 PA patients with Hinchey III peritonitis were well matched to 17
PAS patients. Similar overall morbidity (52% vs. 41%, p=0.45) and severity of complications
requiring re-intervention or ICU stay (18% vs. 24%, p=0.51) were noted. Including the procedure
of stoma reversal, overall blood loss was not different (700 vs. 950 ml, p=0.41), however,
operation time was significantly shorter in PA (169 vs. 320 min, p=0.003) with significantly
shorter overall hospital stay (17 vs. 28 days, p