Partial cricotracheal resection for pediatric subglottic stenosis: a single institution's experience in 60 cases.

In our study, 60 infants and children, each with a severe subglottic stenosis (SGS), underwent partial cricotracheal resection (PCTR) with primary thyrotracheal anastomosis. According to the Myer-Cotton classification, two were grade II, 41 were grade III and 17 were grade IV stenoses. Of the 60 patients, 57 (95%) are presently decannulated, and one patient sustained a complete restenosis. Two patients with better than 80% subglottic airways still are waiting for decannulation: one because of bilateral cricoarytenoid joint fixation and the second because of temporary stenting of the subglottis with a Montgomery T-tube. The rate of decannulation is 97% (36 of 37 cases) in primary PCTRs, 100% (13 of 13 cases) in salvage PCTRs for failed laryngotracheal reconstructions (LTR) and 70% (7 of 10 cases) in extended PCTRs (i.e., PCTR associated with an additional open-airway procedure).

Cardiac and pericardial fistulae associated with esophageal or gastric neoplasms: a literature review

Pericardial and cardiac fistulae secondary to esophageal or gastric tumors are considered exceptional. They have never been the object of a literature review. We reviewed the medical literature between 1881 and 2001, searching for all published cases of pericardial or cardiac fistulae developed from esophageal and gastric tumors or favored by the applied therapy to these tumors. The cases of metastasization, tumor spread, and neoplasic pericardial effusion without fistula were excluded. Fifty patients were identified, with one original case. More than half the cases (56%) occurred in the last 25 years. Substernal pain is the main symptom. The majority of patients present at least one condition favoring fistula formation. The auscultation of a water-wheel murmur may suggest a pneumopericardium and therefore a pericardial fistula, as does a purulent pericarditis. Arrhythmias, signs of ischemia, and hematemesis point toward a ventricular fistula. Neurological and hemostasis disorders may be suspect of an atrial lesion. Diagnosis should be made by the association of a scanner and a transit. Prognosis is bad: 76% of the patients die in the first month. Pericardial or cardiac fistulae are part of the differential diagnosis of thoracic pain in patients with esophageal or gastric tumors and in patients who were treated for these pathologies. The diagnosis must be as quick as possible. An operation (patients with a good prognosis) or the placement of a stent (patients with a bad prognosis) is the only chance of survival

Palliative portal vein stent placement in malignant and symptomatic extrinsic portal vein stenosis or occlusion.

This article evaluates the results of portal vein (PV) stent placement in patients with malignant extrinsic lesions stenosing or obstructing the PV and causing symptomatic PV hypertension (PVHT). Fourteen patients with bile duct cancer (n = 7), pancreatic adenocarcinoma (n = 4), or another cancer (n = 3) underwent percutaneous transhepatic portal venous stent placement because of gastroesophageal or jejunal varices (n = 9), ascites (n = 7), and/or thrombocytopenia (n = 2). Concurrent tumoral obstruction of the main bile duct was treated via the transhepatic route in the same session in four patients. Changes in portal venous pressure, complications, stent patency, and survival were evaluated. Mean +/- standard deviation (SD) gradient of portal venous pressure decreased significantly immediately after stent placement from 11.2 mmHg +/- 4.6 to 1.1 mmHg +/- 1.0 (P < 0.00001). Three patients had minor complications, and one developed a liver abscess. During a mean +/- SD follow-up of 134.4 +/- 123.3 days, portal stents remained patent in 11 patients (78.6%); stent occlusion occurred in 3 patients, 2 of whom had undergone previous major hepatectomy. After stent placement, PVHT symptoms were relieved in four (57.1%) of seven patients who died (mean survival, 97 +/- 71.2 days), and relieved in six (85.7%) of seven patients still alive at the end of follow-up (mean follow-up, 171.7 +/- 153.5 days). Stent placement in the PV is feasible and relatively safe. It helped to relieve PVHT symptoms in a single session.

Interspinous distraction in lumbar spinal stenosis: a neurophysiological perspective.

STUDY DESIGN: Prospective neurophysiological study. OBJECTIVE: To identify and quantify the neurophysiological effects of interspinous distraction during spine surgery for lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: Interspinous devices have been introduced as an alternative treatment of LSS in selected patients aiming at obtaining indirect decompression. Nevertheless, there is no data on the immediate neurophysiological effect of distraction. METHODS: Thirty patients with LSS undergoing decompression (14 at single level, 16 at multiple levels) were enrolled, resulting in a total of 48 levels to be analyzed. Before decompression, calibrated incremental distraction simulating interspinous device implantation of 8, 10, 12, 14, and 16 mm was performed. Intraoperative motor evoked potentials were acquired before any distraction, during distraction at each incremental value and after bilateral decompression. We evaluated relative changes of motor evoked potentials normalized to hand muscles and related them to the number of affected levels, LSS radiological severity based on the A to D grading, lordosis, and disc height. RESULTS: For single-level disease, 8-mm distraction and open decompression yielded similar improvement in motor evoked potentials not only in levels with morphological grades A or B, but also in levels with morphological grades C or D (i.e., severe or extreme stenosis) (P = 0.32). In contrast, distraction superior to 8 mm was less effective (P ≤ 0.05). In multiple-level stenosis, decompression was significantly more effective than any degree of distraction (P < 0.001). No correlation of those results to disc height or lordosis was observed. Using χ trend test to analyze the effect of distraction, a linear trend favoring moderate over severe stenotic morphology was observed (P = 0.0349). CONCLUSION: Interspinous distraction of 8 mm is sufficient to replicate electrophysiological improvements obtained during full decompression even in severe single-level stenosis but not in multilevel disease. Interspinous distraction has therefore an immediately measurable neurophysiological effect. Level of Evidence: 4.

Comparison of transhiatal laparoscopy versus blind closed-chest cervicotomy and laparotomy for esophagectomy in children.

BACKGROUND: Esophageal replacement for caustic stenosis in children poses a challenging surgical problem. Blind removal of the injured esophagus without thoracotomy through a left cervical and transhiatal approach followed by an orthotopic esophageal replacement using either the colon or the stomach is a difficult procedure and can be dangerous in children. We performed our first total laparoscopic transhiatal esophagectomy in February 2007. We aim to compare this new technique to the previously applied method of blind closed-chest esophagectomy through a cervicotomy and laparotomy. METHODS: We analyzed the surgery and follow-up of 40 children operated upon for extensive irreversible caustic burns of the esophagus. The first 20 esophageal replacements were performed following a blind dissection of the mediastinum through a cervical incision and a laparotomy for esophagectomy (Group I). The last 20 esophageal replacements were performed after laparoscopic transhiatal dissection in the mediastinum and cervicotomy in the neck for esophagectomy (Group II). All operations were performed under the supervision of the same senior surgeon. RESULTS: Average age at the time of surgery was the same in both groups. Total esophagectomy was achieved in 45.0% of cases in Group I versus in 90.0% of cases in Group II. Colon was used in 80.0% of cases in Group I and in 90.0% in Group II. The mean duration of surgery was one hour longer in the laparoscopy group. One vascular injury was reported in the blind laparotomy group. Pneumothorax was more frequent in Group II without significant consequences besides drainage. Average time of extubation was about the same in both groups (1.8days). CONCLUSION: Laparoscopic transhiatal esophagectomy for caustic burns before esophageal replacement in children is safe and effective. It could avoid vascular and bronchial mediastinal injuries as the dissection is performed under direct visual control. The routine use of laparoscopic assistance by a senior surgeon improves the safety of esophageal dissection and reduces life-threatening complications.

Prise en charge des sténoses carotidiennes [Management of the carotid artery stenosis].

In the western world, the carotid-artery stenosis is one of the major causes of ischemic stroke in elderly people. The principal therapeutic indication is a symptomatic stenosis > 50% in the first two weeks and the surgical approach has shown the best results. Despite inferior results to carotid endarterectomy in terms of post-operative rate of stroke and/or death, except for young patients, carotid stenting remains the best choice in patients at high surgical risk. The best medical treatment, consisting in correction of cardiovascular risk factors, statin therapy and anti-aggregation led to a drastic reduction in the annual rate of stroke associated to carotid stenosis and thus limited the surgical intervention in asymptomatic patient to men with a life expectancy of at least 5 years and a stenosis > 70%.

Critical single proximal left arterial descending coronary artery stenosis to mimic chronic myocardial ischemia: a new model induced by minimal invasive technology.

BACKGROUND/AIMS: The present report examines a new pig model for progressive induction of high-grade stenosis, for the study of chronic myocardial ischemia and the dynamics of collateral vessel growth. METHODS: Thirty-nine Landrace pigs were instrumented with a novel experimental stent (GVD stent) in the left anterior descending coronary artery. Eight animals underwent transthoracic echocardiography at rest and under low-dose dobutamine. Seven animals were examined by nuclear PET and SPECT analysis. Epi-, mid- and endocardial fibrosis and the numbers of arterial vessels were examined by histology. RESULTS: Functional analysis showed a significant decrease in global left ventricular ejection fraction (24.5 +/- 1.6%) 3 weeks after implantation. There was a trend to increased left ventricular ejection fraction after low-dose dobutamine stress (36.0 +/- 6.6%) and a significant improvement of the impaired regional anterior wall motion. PET and SPECT imaging documented chronic hibernation. Myocardial fibrosis increased significantly in the ischemic area with a gradient from epi- to endocardial. The number of arterial vessels in the ischemic area increased and coronary angiography showed abundant collateral vessels of Rentrop class 1. CONCLUSION: The presented experimental model mimics the clinical situation of chronic myocardial ischemia secondary to 1-vessel coronary disease.

Cardiac rotation and relaxation in patients with aortic valve stenosis.

BACKGROUND: Diastolic dysfunction with delayed relaxation and abnormal passive elastic properties has been described in patients with severe pressure overload hypertrophy. The purpose of this study was to evaluate the time course of rotational motion of the left ventricle in patients with aortic valve stenosis using myocardial tagging. METHODS: Myocardial tagging is a non-invasive method based on magnetic resonance which makes it possible to label ('tag') specific myocardial regions. From the motion of the tag's cardiac rotation, radial displacement and translational motion can be determined. In 12 controls and 13 patients with severe aortic valve stenosis systolic and diastolic wall motion was assessed in an apical and basal short axis plane. RESULTS: The normal left ventricle performs a systolic wringing motion around the ventricular long axis with clockwise rotation at the base (-4.4+/-1.6 degrees) and counter-clockwise rotation at the apex (+6.8+/-2.5 degrees) when viewed from the apex. During early diastole an untwisting motion can be observed which precedes diastolic filling. In patients with aortic valve stenosis systolic rotation is reduced at the base (-2.4+/-2.0 degrees; P<0.01) but increased at the apex (+12.0+/-6.0 degrees; P<0.05). Diastolic untwisting is delayed and prolonged with a decrease in normalized rotation velocity (-6.9+/-1.1 s(-1)) when compared to controls (-10.7+/-2.2 s(-1); P<0.001). Maximal systolic torsion is 8.0+/-2.1 degrees in controls and 14.1+/-6.4 degrees (P<0.01) in patients with aortic valve stenosis. CONCLUSIONS: Left ventricular pressure overload hypertrophy is associated with a reduction in basal and an increase in apical rotation resulting in increased torsion of the ventricle. Diastolic untwisting is delayed and prolonged. This may explain the occurrence of diastolic dysfunction in patients with severe pressure overload hypertrophy.

Airway stenting with the LT-Mold? for severe glotto-subglottic stenosis or intractable aspiration: experience in 65 cases.

The purpose of this study was to assess the safety and efficacy of stenting in upper airway reconstructions for benign laryngotracheal stenosis (LTS) with a newly designed prosthesis, the LT-Mold?. The LT-Mold and its proper use during open surgery and endoscopy are described, and the experience gathered from a prospectively collected database on 65 patients treated for complex LTS or severe aspiration is reported. This series is compared to the results of other stenting methods. All patients were available for evaluation. In all but one case, the prosthesis was removed at the end of the study. The new prosthesis did not induce any stent-related trauma to the supraglottis, glottis and subglottis. Before adding a distal round-shaped silicone cap to the LT-Mold, granulation tissue was usually seen at the stent-mucosal interface at the tracheostoma level. In 14 cases, there has been a spontaneous extrusion of the prosthesis through the mouth; this problem was solved by fixing the prosthesis through the reinforced portion of the prosthesis at the cap level and by adding one fixation stitch in the supraglottis. We have to document the loss of the silicone cap in three cases. This problem was resolved by designing a new prototype with an integrated cap, glued with a slow hardening silicone glue. Fifty-four (83 %) of 65 patients were decannulated after a mean duration of stenting of 3 months (range 1-12 months). The mean follow-up after decannulation was 23 months (range 1 month to 10 years). The experience gathered with the LT-Mold shows that long-term stenting for complex LTS is safely achieved when the prosthesis is used with its distal integrated silicone cap. The softness and smoothness of the prosthesis with a round-shaped configuration of both extremities help avoid ulceration and granulation tissue formation in the reconstructed airway. Adequate fixation is mandatory to avoid extrusion.

Blockade of the Renin-Angiotensin system in hypertensive patients with atherosclerotic renal artery stenosis.

Renin angiotensin system (RAS) blockers are generally considered as contraindicated when an atheromatous renal artery stenosis (ARAS) is diagnosed. The main reason is the fear of inducing renal ischemia and, hence, accelerating renal fibrosis and the progression towards end stage renal disease, albeit RAS blocker have been shown to be highly effective in controlling blood pressure. Part of the solution came by the development of the revascularization. There is now growing evidence showing no superiority of angioplasty over medical treatment on cardiovascular events and mortality, renal function and blood pressure control. Hence, RAS blockers resurfaced based on their proven beneficial effects on blood pressure control and cardiovascular prevention in high risk atherosclerotic patients. Thus, RAS blockers belong today to the standard treatment of hypertensive patients with ARAS. However they were not systematically prescribed in trials focusing on ARAS. The ongoing CORAL trial will give us further information on the place of this class of antihypertensive drugs in patients with ARAS.

Association of biomarkers of lipid modification with functional and morphological indices of coronary stenosis severity in stable coronary artery disease.

Biomarkers of blood lipid modification and oxidative stress have been associated with increased cardiovascular morbidity. We sought to determine whether these biomarkers were related to functional indices of stenosis severity among patients with stable coronary artery disease. We studied 197 consecutive patients with stable coronary artery disease due to single vessel disease. Fractional flow reserve (FFR) ≤ 0.80 was assessed as index of a functionally significant lesion. Serum levels of secretory phospholipase A2 (sPLA2) activity, secretory phospholipase A2 type IIA (sPLA2-IIA), myeloperoxydase (MPO), lipoprotein-associated phospholipase A2 (Lp-PLA2), and oxidized low-density lipoprotein (OxLDL) were assessed using commercially available assays. Patients with FFR > 0.8 had higher sPLA2 activity, sPLA2 IIA, and OxLDL levels than patients with FFR ≤ 0.8 (21.25 [16.03-27.28] vs 25.85 [20.58-34.63] U/mL, p < 0.001, 2.0 [1.5-3.4] vs 2.6 [2.0-3.4] ng/mL, p < 0.01; and 53.0 [36.0-71.0] vs 64.5 [50-89.25], p < 0.001 respectively). Patients with FFR > 0.80 had similar Lp-PLA2 and MPO levels versus those with FFR ≤ 0.8. sPLA2 activity, sPLA2 IIA significantly increased area under the curve over baseline characteristics to predict FFR ≤ 0.8 (0.67 to 0.77 (95 % confidence interval [CI]: 0.69-0.85) p < 0.01 and 0.67 to 0.77 (95 % CI: 0.69-0.84) p < 0.01, respectively). Serum sPLA2 activity as well as sPLA2-IIA level is related to functional characteristics of coronary stenoses in patients with stable coronary artery disease.

Hypertoniebehandlung bei Nierenarterienstenose [Hypertension therapy in patients with renal artery stenosis].

Renovascular hypertension is due to reduced renal parenchymal perfusion. The correct diagnosis can be difficult. It is important to note that the demonstration of renal artery stenosis in a patient with hypertension does not necessarily constitute renovascular hypertension. Often, clinically nonsignificant and asymptomatic renal artery stenosis are found in patients with essential hypertension, or renal failure of other origin. Renovascular disease is a complex disorder with various clinical presentations. In patients with significant renovascular hypertension plasma renin is increased. For this reason the therapy aims to block the renin-angiotensin-aldosterone system. Bilateral renal artery stenosis causes renal sodium retention. In this situation a diuretic drug has to be added to the therapy. Endovascular or surgical therapy has to be considered in patients with flash pulmonary edema or fibromuscular dysplasia. The control of cardiovascular risk factors is important.