E.Charles Douville

Hemi-front operation in surgery for single ventricle: A preliminary report☆

Mortality after Fontan operation is related to risk factors like ventricular hypertrophy, pulmonary artery deformity, and young age (infancy). Preliminary procedures may improve Fontan results. The hemi-Fontan operation includes atriopulmonary anastomosis and correction of all anatomical risk factors, but an atriopulmonary patch directs superior vena caval flow into both pulmonary arteries and inferior vena caval flow into the ventricle, thus maintaining cardiac output (modified Glenn physiology). We performed 17 hemi-Fontan procedures in 16 patients, 14 primarily (median age, 9 months) and 3 for takedown of a Fontan operation. The 14 primary operations were for hypoplastic left heart syndrome (5), pulmonary atresia with intact ventricular septum (4), and other (5). All patients had multiple risk factors. Extubation was at 18 hours (median), chest tube removal was at 3 days, and hospital discharge was at 8 days postoperatively. Important complications included subglottic stenosis, transient diaphragmatic paralysis, pulmonary artery stenosis and thrombosis requiring reoperation, and transient ventricular fibrillation. One patient required hemi-Fontan takedown, and this patient later (3 months postoperatively) became the only death. Fontan take-downs have had a high mortality rate. In 3 patients who tolerated Fontan operation poorly, converting Fontan to hemi-Fontan abruptly reversed the downhill course. For these patients, the operation was life-saving. Hemi-Fontan operation is safe and well-tolerated, even in infants, provides the advantages of modified Glenn physiology before Fontan operation, and may be especially useful for Fontan takedown after failed Fontan.

Subvalvar Aortic Stenosis: Timing of Operation

Subvalvar aortic stenosis can be associated with progressive left ventricular outflow tract obstruction, aortic insufficiency, and infective endocarditis. We reviewed the records of 36 surgical patients who underwent 39 operations for subaortic stenosis. Seventeen patients had associated congenital cardiac anomalies. One perioperative death occurred in a patient with tetralogy of Fallot. The mean preoperative left ventricular outflow tract systolic pressure gradient was 64 +/- 5 mm Hg (+/- standard error of the mean) and decreased to 9 +/- 2 mm Hg postoperatively (p less than 0.001). Reliable preoperative and postoperative information regarding aortic valve function was available for 27 patients. Aortic insufficiency was found in 17 (63%) of those patients preoperatively. Postoperatively, insufficiency increased in 3 patients and decreased in 4; none of these changes was major. Severity of preoperative aortic insufficiency increased significantly with age (p less than 0.05), but did not correlate with left ventricular outflow tract gradient. The information from this study and previous studies suggests that resection of subaortic stenosis is safe and effective, and operation at the time of diagnosis, regardless of left ventricular outflow tract gradient or symptomatic status, is a reasonable therapeutic alternative.

Hospital readmission after pulmonary resection: prevalence, patterns, and predisposing characteristics

BACKGROUND Our objective was to define the prevalence, patterns, and predisposing characteristics for hospital readmission after pulmonary resection. METHODS Five years of pulmonary resections, excluding lung biopsies, were analyzed from a prospective, computerized database. Readmission was defined as inpatient or emergency department admission within 90 days of operation. Search of 1,173,912 admissions to the Providence Health System in Oregon identified readmissions. Readmission analysis excluded operative deaths. RESULTS A total of 374 patients underwent pulmonary resections, of whom 8 died (2.1%). Of 366 patients discharged, 69 (18.9%) were readmitted a total of 113 times: 42 had only one readmission, 16 had two readmissions, 7 had three readmissions, 2 had four readmissions, and 2 had five readmissions. Slightly more than half (51%) were readmitted as inpatients. Causes of the 113 readmissions included pulmonary (27%), postoperative infection (14%), cardiac (7%), and other (16%). Mean time to readmission was 32.5 +/- 24.6 days. Inpatient readmission mean length of stay was 4.9 +/- 3.4 days. Readmission to hospitals other than the hospital of the operation was as follows: first readmission, 15.9%; second readmission, 14.8%; third readmission, 36.3%; fourth readmission, 25%; fifth readmission, 0%. Analysis revealed only pneumonectomy as a risk for readmission. Twelve of 33 (36%) pneumonectomies were readmitted (p = 0.005). Of the 297 patients discharged after pulmonary resection and not requiring readmission, 12 (4%) died over the study interval, whereas 8 of 69 patients (11.6%) requiring readmission died. CONCLUSIONS Readmission after pulmonary resection is frequent and multiple readmissions are common. Causes are predominately pulmonary diagnoses and infections related to the operation. Pneumonectomy is a risk for readmission. An important portion of readmissions occurs outside the hospital of operation. The population requiring readmission after successfully undergoing pulmonary resection is at increased risk of subsequent mortality.

Median sternotomy versus thoracotomy to resect primary lung cancer: analysis of 815 cases

BACKGROUND We sought to determine if median sternotomy (MS) is an equivalent incision to thoracotomy (TH) in the treatment of primary pulmonary carcinoma. METHODS We followed 801 patients undergoing 815 operations for primary lung carcinoma in a computer registry; 447 had MS, 368 had TH. RESULTS Both groups were similar in preoperative risk assessment. Complete staging lymph node dissections were performed in 42% of MS patients and 17% of TH patients. Operative mortality (3.8% for MS, 3.3% for TH) and postoperative complications were similar. MS patients had a shorter postoperative hospital stay (7.5 days vs. 8.2 days). One hundred thirty-nine underwent pneumonectomy. Operative mortality was 12.5% for MS and 10.4% for TS (p = NS). Five hundred eighty-one underwent lobectomy with an operative mortality of 2.1% for MS and 2.0% for TH. Mean length of stay for MS lobectomy was 7.5 days compared with 8.5 days for TH (p = 0.06). Follow-up was 89% through 1998, comprising 1,339 MS and 1,463 TH patient-years. Survival for stage I at 5 and 10 years, respectively, was 51% and 34% for MS vs 54% and 32% for TH (p = NS). Survival for other stages was also similar. CONCLUSIONS Median sternotomy provides more complete staging, shorter postoperative hospitalization, and better patient acceptance with equivalent operative and long-term survival when compared with thoracotomy. Concerns regarding increased wound infections in MS patients appear unfounded.