Establishing and clinically validating a machine learning model for predicting unplanned reoperation risk in colorectal cancer

BACKGROUND Colorectal cancer significantly impacts global health,with unplanned reoperations post-surgery being key determinants of patient outcomes.Existing predictive models for these reoperations lack precision in integrating complex clinical data.AIM To develop and validate a machine learning model for predicting unplanned reoperation risk in colorectal cancer patients.METHODS Data of patients treated for colorectal cancer(n=2044)at the First Affiliated Hospital of Wenzhou Medical University and Wenzhou Central Hospital from March 2020 to March 2022 were retrospectively collected.Patients were divided into an experimental group(n=60)and a control group(n=1984)according to unplanned reoperation occurrence.Patients were also divided into a training group and a validation group(7:3 ratio).We used three different machine learning methods to screen characteristic variables.A nomogram was created based on multifactor logistic regression,and the model performance was assessed using receiver operating characteristic curve,calibration curve,Hosmer-Lemeshow test,and decision curve analysis.The risk scores of the two groups were calculated and compared to validate the model.RESULTS More patients in the experimental group were≥60 years old,male,and had a history of hypertension,laparotomy,and hypoproteinemia,compared to the control group.Multiple logistic regression analysis confirmed the following as independent risk factors for unplanned reoperation(P<0.05):Prognostic Nutritional Index value,history of laparotomy,hypertension,or stroke,hypoproteinemia,age,tumor-node-metastasis staging,surgical time,gender,and American Society of Anesthesiologists classification.Receiver operating characteristic curve analysis showed that the model had good discrimination and clinical utility.CONCLUSION This study used a machine learning approach to build a model that accurately predicts the risk of postoperative unplanned reoperation in patients with colorectal cancer,which can improve treatment decisions and prognosis.

Reoperation for heterochronic intraductal papillary mucinous neoplasm of the pancreas after bile duct neoplasm resection:A case report

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)and intraductal papillary mucinous neoplasm(IPMN)of the pancreas have similar pathological manifestations.However,they often develop separately and it is rare for both to occur together.Patients presenting with heterochronic IPMN after IPNB are prone to be misdiagnosed with tumor recurrence.CASE SUMMARY A 67-year-old male patient was admitted 8.5 years after IPNB carcinoma and 4 years after the discovery of a pancreatic tumor.A left hepatic bile duct tumor with distal bile duct dilatation was found 8.5 years ago by the computed tomography;therefore,a left hepatectomy was performed.The postoperative pathological diagnosis was malignant IPNB with negative cutting edge and pathological stage T1N0M0.Magnetic resonance imaging 4 years ago showed cystic lesions in the pancreatic head with pancreatic duct dilatation,and carcinoembryonic antigen continued to increase.Positron emission tomography showed a maximum standard uptake value of 11.8 in the soft tissue mass in the pancreatic head,and a malignant tumor was considered.Radical pancreatoduodenectomy was performed.Postoperative pathological diagnosis was pancreatic head IPMN with negative cutting edge,pancreaticobiliary type,stage T3N0M0.He was discharged 15 d after the operation.Follow-up for 6 mo showed no tumor recurrence,and quality of life was good.CONCLUSION IPNB and IPMN are precancerous lesions with similar pathological characteristics and require active surgery and long-term follow-up.

Erratum:Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

This is an erratum to an already published paper.We found an error in the results section and Table 1.Specifically,we have revised results with n≤10 to be reflected as such,which is consistent with the reporting instructions by the Agency for Healthcare Research and Quality.Please note,these changes do not affect our results,and we had previously listed this requirement in the results section.We apologize for our unintentional mistake.

Risk Factors of Reoperation and Outcome of Patients Operated for Chronic Subdural Hematoma in a Teaching Hospital in Rabat

Background: chronic subdural hematoma is a common pathology, especially in the elderly. Although it has a good prognosis, it poses the problem of recurrence after surgical evacuation. Objective: To analyze the risk factors of reoperation in patients surgically treated for chronic subdural hematoma (cSDH) and evaluate the outcome of patients who benefited from a reoperation. Materials and Methods: A retrospective review was conducted in a single University Hospital Center in Rabat (Morocco) on 49 patients operated on from January 2020 to June 2021 for cSDH. Possible risk factors described in the literature were analyzed and the outcome of post-operative course was evaluated. Statistical significance was defined by p-value Results: 49 patients underwent surgical evacuation of cSDH. The sex ratio of male/female was 3.08. The mean age was 70.6 years. Concerning the medical history, 8.2% were diabetics, 10.2% had heart disease, 18.4% had hypertension, 16.3% associated of comorbidities, 2% had pulmonary embolism, and 2% had neoplasm. 18.4% were on anticoagulation therapy, no patients were on new oral anticoagulants. The clinical findings upon admission were motor deficit at 57.1%, signs of intracranial hypertension at 20.4%, altered consciousness at 16.9% and impaired behavior at 6.1%. 28.6% of patients had a past history of head trauma. The pre-operative CT scan showed unilateral cSDH at 81.6%, midline shifts at 77.6%, and false membranes at 34.7%. Blood appeared chronic at 40.8%, subacute at 24.5%, and mixed densities at 34.7%. The post-operative course was uneventful in 73.5%. According to Ibanez grading 8 patients had mild complications (grade I) and 5 moderate complications (grade II) after the first surgery. We recorded 10.2% of patients who needed a second surgery because of the deterioration of neurologic status or motor deficit associated with an abnormal CT scan. According to the GOS, 85.7% of patients had a good recovery while 10.2% died. None of the factors assessed was found to be a risk factor for reoperation. Conclusion: No risk factors of reoperation after an initial burr hole evacuation for cSDH were found. However medical history and male sex was common condition among reoperated patients with their CT scan showing a chronic aspect of blood, midline shift and false membranes. Most patients who underwent revision surgery died on the postoperative course.

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM:To investigate the occurrence of postoperative complications of gastric cancer surgery,and analyze the potential causes of reoperation for early postoperative complications. METHODS:A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study.The study endpoint was the analysis of postoperative complications in inpatients. RESULTS:About 31%of patients had early postoperative complications,and complications of infection occurred most frequently.Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation,which accounted for about 2.2%.Mortality was 11.1%in the reoperation group,but was only 0.8%in other patients.The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation(P<0.001).There was no significant association of any available factors in this study with the high rate of reoperation.CONCLUSION:Reoperation significantly increases the mortality rate and raises the burden of the surgical unit.More prospective studies are required to explore the potential risk factors.

Reoperation of biliary tract by laparoscopy:Experiences with 39 cases

AIM:To evaluate the safety and feasibility of biliary tract reoperation by laparoscopy for the patients with retained or recurrent stones who failed in endoscopic sphincterotomy. METHODS:A retrospective analysis of data obtained from attempted laparoscopic reoperation for 39 patients in a single institution was performed, examining open conversion rates, operative times, complications, and hospital stay. RESULTS:Out of the 39 cases, 38 (97%) completed laparoscopy, 1 required conversion to open operation because of difficulty in exposing the common bile duct. The mean operative time was 135 min. The mean post-operative hospital stay was 4 d. Procedures included laparoscopic residual gallbladder resection in 3 cases, laparoscopic common bile duct exploration and primary duct closure at choledochotomy in 13 cases, and laparoscopic common bile duct exploration and choledochotomy with T tube drainage in 22 cases. Duodenal perforation occurred in 1 case during dissection and was repaired laparoscopically. Retained stones were found in 2 cases. Postoperative asymptomatic hyperamlasemia occurred in 3 cases. There were no complications due to port placement, postoperative bleeding, bile or bowel leakage and mortality. No recurrence or formation of duct stricture was observed during a mean follow-up period of 18 mo. CONCLUSION:Laparoscopic biliary tract reoperation is safe and feasible if it is performed by experiencedlaparoscopic surgeons, and is an alternative choice for patients with choledocholithiasis who fail in endoscopic sphincterectomy.

Reoperation for benign biliary tract diseases in 149 cases: causes and prevention

BACKGROUND: Failure to diagnose and treat benign bi- liary tract disease relatively common surgical disease may cause serious consequences. Since the introduction of B- mode ultrasonography, CT, or MRI early and accurate diagnosis of the disease has been possible. In clinical prac- tice, however, these methods have not been adequately used. Inappropriate surgical procedures can also lead to bile duct injury or stenosis after injury, residual cholecystitis, stenosis after cholangiojejunostomy, or stenosis of the Od- di' s sphincter. But improvement of the diagnosis and treat- ment of benign biliary tract disease remains a great chal- lenge to clinicians. METHODS: A total of 149 patients with benign biliary tract disease who had received reoperation from June 1988 to June 2001 were analyzed retrospectively. Among them 95 patients (63.76%) received operation twice and 38 (25.5%) underwent 3 operations. Sixteen patients (10.74%) needed 4 or more operations. The procedures for the first opera- tion included cholecystectomy (71 patients, 47.65%), cho- lecystectomy with exploration of the common bile duct (42, 28.19%), cholangiojejunostomy (21, 14.1%), and la- paroscopic cholecystectomy (15, 10.06%). RESULTS: The causes for reoperation included residual and recurrent bile duct stones in 53 patients (35.57%), bile duct injury or stenosis after injury in 41 (27.52%), residual cho- lecystitis with or without stones in 28 (18.8%), stenosis af- ter cholangiojejunostomy in 17 (11.41%), stenosis of the Oddi's sphincter in 5 (5.35%), and others in 5 (5.35%). Four patients (2.68%) died after operation. CONCLUSIONS: To prevent reoperation for benign biliary tract diseases, the following measures should be taken to in- crease preoperative diagnostic rate, to understand condi- tions of the biliary tract by using imaging techniques and cholangiography, to examine comprehensively and careful- ly with choledochoscopy, cholangiography and B-mode ul-trasonography intraoperatively, to choose appropriate ope- rative procedures to decrease the rate of residual stones, and to decide the time for the first repair according to inju- ry type of the bile duct. Roux-en-Y hepaticojejunostomy with cholangioplasty is the best operation for the recon- struction of the biliary tract.

Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth Ⅱ or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes:(1) entrapment, compression and kinking by postoperative adhesions;(2) internal herniation, volvulus and intussusception;(3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop;(4) cancer recurrence; and(5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluidfilled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes:(1) adhesiolysis and reconstruction for benign causes; and(2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.

Cause analysis and reoperation effect of failure and recurrence after epiblepharon correction in children

BACKGROUND In children, it is common to see failure and recurrence in the correction ofepiblepharon and to have reoperation due to obvious irritation symptoms andcorneal injury.AIM To explore the causes of failure and recurrence after epiblepharon correction inchildren, to remove accurately redundant epiblepharon and orbicularis oculimuscle in patients via the cilia-everting suture technique combined with lidmargin splitting in some patients due to inverted lashes in the medial part of theeyelid, and to observe the therapeutic effect.METHODS From 2015 to 2019, in the Outpatient Department of Ophthalmology of BeijingTongren Hospital, 22 children (40 eyes) with epiblepharon, aged 5-12 years, weretreated due to correction failure and recurrence. Fourteen patients (28 eyes)underwent the full-thickness everting suture technique, and eight patients (16eyes) underwent incisional surgery. They were treated by reviewing the previoussurgical methods and observing epiblepharon, eyelash direction, and cornealinjury. During reoperation, a subciliary incision was made 1 mm below theinferior lash line. Incisional surgery for the lower eyelid was used to removeaccurately redundant epiblepharon and part of the pretarsal orbicularis muscle.Subcutaneous tissue and the orbicularis muscle of the upper skin-muscle flapwere anchored to the anterior fascia of the tarsal plate by rotational sutures. Lidmargin splitting was used only for patients who had seriously inverted lasheslocated in the medial part of the eyelid. All patients were followed for 6-12 moafter reoperation to observe the lower eyelid position, skin incision, eyelash direction, corneal damage, and recurrence.RESULTS After reoperation, all the patients were corrected. Photophobia, rubbing the eye,winking, and tearing disappeared. There was no lower eyelid entropion,ectropion, or retraction. There was no obvious sunken scar or lower eyelid crease.The eyelashes were far away from the cornea, and when the patients lookeddown, the eyelashes on the lower eyelid did not contact the cornea or conjunctiva.The corneal injuries were repaired. Follow-up observation for 6 mo showed norecurrence of epiblepharon.CONCLUSION The type of suture method, the failure to remove accurately redundant skin andorbicularis muscle, the lack of cilia rotational suture use, and excessive reversegrowth of eyelashes are the main causes of failure and recurrence afterepiblepharon correction in children.

Clinical outcomes after intrastromal corneal ring segments reoperation in keratoconus patients

AIM:To evaluate the clinical outcomes after Ferrara intrastromal corneal ring segments(ICRS)reoperation in patients with keratoconus.METHODS:A total of 37 keratoconus eyes implanted with intrastromal corneal ring segments,which had an ICRS exchange,addition,reposition or removal were evaluated.Uncorrected visual acuity(UCVA),best corrected visual acuity(BCVA),keratometry(K),asphericity(Q)and pachymetry at the thinnest point(PTP)of the cornea were evaluated using a corneal tomography(Oculus Pentacam,USA)RESULTS:The mean follow-up time after the reoperation was 30.5±9.7 months.The mean UCVA improved from 20/300 to 20/80(P=0.005);the mean BCVA improved from 20/160 to 20/50(P=0.0002),the mean keratometry reduced from 49.33±4.19D to 46.16±3.90D(P=0.0001),the mean pachymetry at the thinnest point increased from 450±42.9μm to 469±40.8μm(P=0.0001).The asphericity increased from-0.84±0.74 to-0.35±0.81(P=0.15)and the spherical equivalent reduced from-4.64±4.87D to-3.04±3.45D(P=0.137).The changes in the asphericity and spherical equivalent were not statistically significant.CONCLUSION:Ferrara ICRS implantation showed to be a reversible and readjustable surgical procedure for keratoconus treatment.Good outcomes can be obtained even after removal,addition,reposition or exchange of ICRS.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

BACKGROUND The national rates of readmission and reoperation after open reduction internal fixation(ORIF)of midshaft clavicle fractures in adolescents is unknown.AIM To determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.METHODS This retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012.Readmissions within ninety days,reoperations within two years,and differences in patient demographic factors were determined through descriptive,univariate,and multivariate analyses.RESULTS In total,3.29%(n=11)of patients were readmitted within 90 d to a hospital at an average of 18.91±18 d after discharge,while 15.87%(n=53)of patients underwent a reoperation within two years at an average of 209.53±151 d since the index surgery.The most common reason for readmission was a postoperative infection(n<10).Reasons for reoperation included implant removal(n=49)at an average time of 202.39±138 d after surgery,and revision ORIF(n<10)with an average time of 297±289 d after index surgery.The odds of reoperation were higher for females(P<0.01)and outpatients(P<0.01),while the odds of reoperation were lower for patients who underwent surgery in California(P=0.02).CONCLUSION There is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents.There are significant differences for reoperation based on patient sex,location,and hospital type.

Reoperation in an adult female with "right-sided" Hirschsprung's disease complicated by refractory hypertension and cough

Hirschsprung's disease(HD) is an intestinal malformation caused by the innate absence of ganglion cells in the neural plexus of the colorectal wall, and is most common in male infants. It is rare in adult, and is usually left-sided. Herein we reported based on the CARE guidelines a case of a 47-year-old adult female suffering from "right-sided" HD complicated by refractory hypertension and cough. The patient with a history of cesarean section and with digestive unfitness(abdominal pain, distention, and constipation) only since 20 years old had recurrence of HD after initial surgery due to the incomplete removal of the HD-affected bowel based on a diagnosis of "chronic ileus", leading to the relapse of the digestive symptoms and the emergence of some intractable circulatory and respiratory complications which could be hardly controlled by conservative treatment. During the long interval before coming to our department for help, she had been re-hospitalized for several times with various misdiagnoses and supplied merely with symptomatic treatment which could only achieve temporary symptomatic relief. At her admission to our department, the imaging examinations strongly indicated recurrent HD which was further supportedb y p a t h o l o g i c a l e x a m i n a t i o n s, a n d r i g h t h e m i-colectomy was performed to remove the remnant aganglionic intestinal segment. Intraoperative and postoperative pathology supported the completeness of the definitive resection. Post-operation, the patient's bowel motility significantly improved, and interestingly, the complications disappeared. For adult patients with long-term constipation combined with cough and hypertension, rare diseases like HD which requires definite surgery and which could be "right-sided" should not be overlooked. It is vital to diagnose and cure HD patients in childhood. Through the comparison of the two surgeries, it is noteworthy that for diagnosed HD, sufficient removal of the non-functional intestine confirmed by intraoperative pathology is essential.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

The present letter to the editor is a commentary on the study titled“Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents”.There is a debate over whether surgical treatment of clavicle shaft fractures improves clinical outcomes in adolescents.The readmission and reoperation rates following surgery should be identified.

The relationship between abduction deficit and reoperation among patients with infantile esotropia

AIM： To determine the relationship between abduction deficit and reoperation among patients with infantile esotropia （IET）. METHODS： The records of 216 patients （432 eyes） with lET who underwent surgery, from 2010 to 2015 were studied. Patients with lET whose deviation appeared before 6mo of age and had stable preoperative deviation in two examinations with at least 2wk apart and a minimum 3too postoperative follow up were included. Cases with early onset accommodative esotropia, congenital cataract, retinopathy of prematurity （ROP）, manifest nystagmus, fundus lesions, neurologic and ophthalmic anomalies, 6th nerve palsy and Duane＇s syndrome were excluded. Preoperative abduction deficit was considered from -1 to -3 grading scale. Three months after surgery, children were classified into no-need reoperation [deviation〈15 prism diopters （PD）], and need-reoperation groups （deviaUon〉15 PD）. RESULTS： In this retrospective study, 117 female and 99 male patients with the mean surgical age of 4.7±6.4y were included. Reoperation rate was 33.3% and 16.0% in lET patients with and without abduction deficit, respectively in patients who had a history of late surgery. Abduction deficit increased the odds of reoperation by 82% [OR=1.82, 95% confidence interval （CI） =1.05 to 3.19, P=0.003] in patients who had a history of late surgery （〉2 years old, P=0.021）. Abduction deficit was improved significantly after operation （P〈0.001）. CONCLUSION： Based on our results, abduction deficit can be considered as a risk factor of reoperation in lET patients who are operated at the age of more than 2y.

Urgent reoperation early after coronary artery bypass graft

Objective To explore the cause of acute myocardial ischemia early after coronary artery bapass graft (CABG) and surgical management on it. Methods From 2001 to 2009,28 patients underwent urgent reoperation early after CABG due to acute myocardial ischemia. The incidence of reoperation is about 0. 02% . The cause of reoperation inclouded early

Modified onlay island flap versus tubularized incised plate urethroplasty for hypospadias reoperation

This study aimed to assess the outcomes of modified onlay island flap(MOIF)urethroplasty for hypospadias reoperation.A retrospective analysis was conducted using clinical data on children reoperated with MOIF or tubularized incised plate(TIP)urethroplasty for hypospadias in the Children's Hospital of Nanjing Medical University(Nanjing,China)from December 2016 to September 2020.A total of 90 children with hypospadias who failed primary repair and were reoperated on with MOIF(MOIF group,n=46)or TIP urethroplasty(TIP group,n=44)were recruited.All children were postoperatively followed up for at least 6 months.Six patients with postoperative urinary fistula,2 patients with glans dehiscence,and 1 patient with urethral diverticulum were reported in the MOIF group,while 7 patients with postoperative urinary fistula,2 patients with urethral stricture,and 1 patient with glans dehiscence were reported in the TIP group.Postoperative infection,flap necrosis and other complications were not recorded.A total of 37(80.4%)patients in the MOIF group and 34(77.3%)patients in the TIP group were successfully reoperated.Although the success rates of MOIF and TIP urethroplasty are comparable,pediatricians should master different types of repair techniques for individualized hypospadias reoperation.MOIF urethroplasty can be recommended after failure of the primary repair.

Radical cholecystectomy without liver resection for peritoneal side early incidental gallbladder cancer

Gallbladder cancer(GBC)is a rare disease with a poor prognosis.Simple cholecystectomy may be an adequate treatment only for very early disease(Tis,T1a),whereas reoperation is recommended for more advanced disease(T1b and T2).Radical cholecystectomy should have two fundamental objectives:To radically resect the liver parenchyma and to achieve adequate clearance of the lymph nodes.However,recent studies have shown that compared with lymph node dissection alone,liver resection does not improve survival outcomes.The oncological roles of lymphadenectomy and liver resection is distinct.Therefore,for patients with incidental GBC without liver invasion,hepatic resection is not always mandatory.

Readmission rate and early complications in patients undergoing total knee arthroplasty:A retrospective study

BACKGROUND Total knee arthroplasty(TKA)can improve pain,quality of life,and functional outcomes.Although uncommon,postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery.Identification of the risk factors for complications and readmissions after TKA,taking into account common causes,temporal trends,and risk variables that can be changed or left unmodified,will benefit this process.AIM To assess readmission rates,early complications and their causes after TKA at 30 days and 90 days post-surgery.METHODS This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1,2017,and February 28,2022.Of the 633 patients,28 were not contactable,leaving 609 who met the inclusion criteria.Both inpatient and outpatient hospital records were retrieved,and observations were noted in the data collection forms.RESULTS Following TKA,the 30-day and 90-day readmission rates were determined to be 1.1%(n=7)and 1.8%(n=11),respectively.The unplanned visit rate at 30 days following TKA was 2.6%(n=16)and at 90 days was 4.6%(n=28).At 90 days,the unplanned readmission rate was 1.4%(n=9).Reasons for readmissions included medical(27.2%,n=3)and surgical(72.7%,n=8).Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group(P=0.922),body mass index(BMI)(P=0.633),unilateral vs bilateral TKA(P=0.696),or patient comorbidity status(30-day P=0.171 and 90-day P=0.813).Reoperation rates after TKA were 0.66%(n=4)at 30 days and 1.15%(n=8)at 90 days.The average length of stay was 6.53 days.CONCLUSION In this study,there was a low readmission rate following TKA.There was no significant correlation between readmission rate and patient factors such as age,BMI,and co-morbidity status.

Reoperations for occluded arterial bypasses in the lower limbs

Background We reviewed the outcomes of reoperations for 29 patients （30 limbs） who had undergone occluded arterial bypass in the lower limbs from May 1996 to September 2005. Methods The 30 lower limbs of the 29 patients with arteriosclerotic obstruction received 44 reoperations, including thrombectomy alone （group T, 27） and inflow or outflow reconstruction plus thrombectomy （group C, 17）. Among the 17 operations in group C, 17.6% （3/17） were inflow reconstructions involving the axillary-femoral （1）, aorta-iliac （1） and aorta-femoral （1） arteries, and 76.4% （13/17） outflow reconstructions involving the femoral-popliteal bypass-tibial （8）, femoral-tibial （1）, femoral-popliteal bypass-popliteal arteries below the knee （2）, and the femoral-popliteal bypass-tibial-peroneal trunk （2）. One patient （1 limb） underwent both inflow and outflow reconstructions with an iliac arterial stent and a graft-popliteal anastomosis patch. Polytetrafluoroethylene （PTFE） grafts were used in the inflow or outflow reconstructions above the knee. Autovenous grafts or autovenously combined PTFE grafts were used in the outflow reconstructions below the knee. Results The percentages of Fontaine stage Ⅲ and IV before primary operation and reoperation were 60% （18/30） and 86.7% （26/30）, respectively （P〈0.05）. Four patients died of heart attack （2）, stroke （1） and multiple organ failure （1） after reoperations. Among them, only 1 patient underwent occluded bypass, and others, patent bypass. Five patients after patent bypass are still alive. The accumulative patent rate was 28.6% （8/28）. The average duration of patency in groups T and C was （4.16±5.68） （0.13- 24） months and （7.14±6.37） （0.26-21） months, respectively （P〉0.05）. Among 42 reoperations, 19 failed within 1 month in groups T （16） and C （3） （P〈0.01）. Nine patients had limb amputated （10/28 limbs, 35.71%） because of graft infection （2 limbs）, pseudo aneurysm at anastomosis （1 limb）, and gangrene caused by failed grafts （7 limbs）. The amputation was performed on 6 limbs within 1 month and on 4 limbs 1 month after reoperation （P〉0.05）. The rate of limb salvage was 64.29% （18/28）. Conclusions The percentages of Fontaine stageⅢ and Ⅳ before reoperation may be much higher than those before primary operation. Thrombectomy plus inflow/outflow reconstruction creates patency better than thrombectomy alone for re-occluded bypass.

Reoperation on aortic disease in patients with previous aortic valve surgery

Background Aortic valve replacement （AVR） is a safe and effective method in the treatment of aortic valve diseases. This study aimed to increase the understanding on re-treatment of aortic diseases after aortic valve surgery through a retrospective analysis of 47 related cases. Methods Forty-seven patients （38 males and 9 females） with previous aortic valve surgery have received reoperation on aorta from January 2003 to June 2012, and the mean interval time of re-intervention to aortic disease was 6 years （（6.0＋ 3.8） years）. The secondary aortic surgery included aortic root replacement （14 cases）, ascending aorta replacement （10 cases）, aortic root/ascending aorta plus total arch replacement with stented elephant trunk implantation （21 cases）, and total thoracoabdominal aorta replacement （2 cases）. All these patients have received outpatient re-exams or follow-up by phone calls, Results After the initial aortic valve replacement, patients suffered from aortic dissection （25 cases, 53%）, ascending aortic aneurysm （12 cases, 26%） or aortic root aneurysm （10 cases, 21%）, Diameter in ascending aorta increased （5.2＋7.1） mm per year and aortic sinus （3.3＋3.1） mm per year. The annual growth value of diameter in ascending aorta was higher in patients with rheumatic heart disease than that in Marfan syndrome （P〈0,05）. All 47 patients have received reoperation on aorta. One patient died in operating room because aortic dissection seriously involved right coronary artery. Seven patients had renal insufficiency after operation; neurological complications occurred in 14 patients including 7 patients with stroke and the others with transient brain dysfunction. All patients were followed up, the mean survival time was （97.25~17.63） months, 95% confidence interval was 55.24-73.33 months. Eight cases were died during follow-up and five-year survival rate was 83%. Conclusion To reduce the aortic adverse events after first aortic valve surgery, it is necessary to actively treat and strictly follow-up patients with previous aortic operation especially patients with Marfan syndrome and rheumatic heart disease.