This paper reports twelve patients underwent repeat hepatic resection because of the recurrence of hepatocellular carcinomas after primary resection. The indication of reoperation, selection of incision, difficults encountered in the operation and the treatment after operation are discussed. The authors believe that the second operation is technically more difficult than the first one, some troubles my be happened during the operation and put forward some ways to deal with this situations.
Abstract： Objective To summarize surgical experiences and explore risk factors of patients undergoing repeated heart valve surgery. Methods Clinical records of 325 consecutive patients who underwent repeated heart valve surgery from January 1998 to December 2008 in Changhai Hospital of Second Military Medical University were retrospectively analyzed. There were 149 male patients and 176 female patients with their average age of （47.1±11.8） years. Following variables were collected: preoperative morbidity， heart function， indications and surgical strategies of repeated heart valve surgery， postoperative mortality and morbidity， which were compared with those clinical data of patients who underwent their first heart valve surgery during the same period. Multivariate logistic regression was used to determine risk factors of perioperative death of patients undergoing repeated heart valve surgery. Results The main reasons for repeated heart valve surgery were mitral valve restenosis after closed mitral commissurotomy and new other valvular diseases. Postoperatively， 28 patients died in the early-stage with the overall mortality of 8.6% （28/325）. The main reasons of in-hospital death included low cardiac output syndrome （LCOS）and acute renal failure. Compared with patients undergoing their first heart valve surgery， patients who underwent repeated heart valve surgery were more likely to have chronic obstructive pulmonary disease （COPD)， New York Heart Association (NYHA） classⅢ-Ⅳ， and atrial fibrillation， preoperatively. Their cardiopulmonary bypass time and aortic cross clamp time were comparatively longer. They also had more postoperative morbidities such as LCOS， acute renal failure and acute respiratory distress syndrome （ARDS）. Multivariate logistic regression showed that preoperative critical state （OR=2.82， P=0.002）， cardiopulmonary bypass time longer than 120 minutes （OR=1.13， P=0.008）， concomitant coronary artery bypass grafting （OR=1.64， P=0.005）， postoperative LCOS（OR=4.52， P＜0.001）， ARDS （OR=3.11， P＜0.001） and acute renal failure （OR=4.13， P＜0.001）were independent risk factors of perioperative death of patients undergoing repeated heart valve surgery. Conclusion Repeated heart valve surgery is a difficult surgical procedure with comparatively higher risks. Full preoperative assessment of the valvular lesions， proper timing for surgery and perioperative management are helpful to reduce postoperative mortality and morbidity.
Objective To analyze the causes of mechanical valve dysfunction and the reconstructive surgical procedure, and summarize the treatment experiences in perioperative period. Methods From October 1996 to October 2008, 12 276 patients underwent mechanical valve replacement in Fu Wai Hospital. Thirtytwo of them were reoperated because of mechanical valve dysfunction. There were 12 male and 20 female aged from 1661 years with an average age of 43.8 years. All the reoperations were performed under hypothermic cardiopulmonary bypass, including 16 mitral valve replacement, 8 aortic valve replacement, 3 aortic and mitral valve replacement, 3 tricuspid valve replacement, 2 disc rotation and 1 excision of an excessive knot. There were 13 emergency operation and 19 elective operation. Results The time of ventilator assistant respiration was 5.1-144.0 hours.The median time was 15 hours and tracheostomy was needed in 2 cases. Six patients died after reoperations, the mortality rate was 18.8%(6/32). Three died of low cardiac output syndrome, 2 died of multiple organ failure and 1 died of malignant arrhythmia. Three cases had complications. There were 1 infective endocarditis, 1 intractable hiccup and 1 incisional infection, respectively. They were all cured and discharged. Conclusion Prosthetic valve dysfunction is one of the serious complications after mechanical valve replacement. Early detection, early diagnosis and early reoperation are needed.
Abstract:Objective To investigate the reoperation indication,surgical timing and the key point of surgical treatment of prosthetic valve endocarditis （PVE） after valve replacement. Methods From February 2000 to July 2005,18 patients with PVE underwent surgery ,their clinical manifestation ,process of treatment and their prognosis outcome were analyzed. Results There were 3 patients （16.7 %） of early-death, 1 patient died of septic shock, and 2 patients died of multiple organ failure. Since 2003,there was no operative death for all 11 patients. There were 6 patients with respiratory insufficiency, 2 patients with renal insufficiency,which were recovered after treatment. The 15 survivors were followed up from 1 month to 5years. There was recurrence of infection in 1 patient who died after ineffective medical treatment. The other 14 patients recovered well. Conclusion It has high risk and high mortality for reoperation for PVE. Accurate reoperative indication,optimal surgical timing,radical debridment of infected tissue and correct perioperative use of antibiotics are the key factors to improve the reoperative result for PVE.
To assess long-term outcomes of reoperation for recurrent lumbar disc herniation, and to compare results of different methods. Methods There were 95 patients who had reoperation for recurrent lumbar discherniation between February 1998 to February 2003, among whom a total of 89 (93.7%) were followed up and their primary data were reviewed. There were 76 patients, with the mean age of 42 years (range from 23 to 61), who met the inclusion criteria and were included. Among them, there were 55 males and 21 females. All patients had the history of more than one sciatic nervepain. The mean recurrent time was 69 months(range from 8 to 130 months). There were 48 patients in L4,5 and 28 patients in L5, S1, of whom we chose 30 to undergo larger vertebral plate discectomy (or two-side fenestration) and nucleus pulpose discectomy (group A), 24 to undergo the whole vertebral discectomy (group B) and 22 to undergo the whole vertebral discectomy and 360degrees intervertebral fusion(group C). The patients’ cl inical results in the three groups were compared, and the cl inical curative effects were evaluated by using cl inical functional assessment standard. Results Cl inical outcomes were excellent or good in 80.3% of the patients, including 80.0% of group A, 79.2% of group B and 81.8% of group C. There was no significant difference in each group (P gt; 0.05). These three groups were not different in age, pain-free interval and follow-up duration (P gt; 0.05). The mean intraoperative blood losses in the three groups were (110.7 ± 98.8), (278.7 ± 256.3), (350.7 ± 206.1) mL, respectively. The mean surgery time were (65.9 ± 22.8), (111.6 ± 24.3), (127.3 ± 26.7) minutes, respectively, and the mean hospital ization time were (6.7 ± 1.4), (10.2 ± 1.8), (12.2 ± 2.3) days, respectively. Group A was significantly less than group B or C (P lt; 0.05) and there was no significant difference between group B and C. All the patients were followed up for 36 to 96 months with an average of 86 months, and with (87.6 ± 27.0), (84.5 ± 19.8), (83.6 ± 13.5) months of group A, B and C, respectively. At the endof the follow-up, there were more cases of spinal instabil ity at the same level in group B (19 patients) than in group A (1 patient) or group C (no patient) in X-ray, and the difference was significant (P lt; 0.05). Conclusion Reoperation for recurrent lumbar disc herniation is effective. Larger vertebral plate discectomy or tow-side fenestration is recommended for managing recurrent lumbar disc herniation.
Objective To analyze the causes and the reoperation therapies after salvage limb surgery with prosthesis for bone tumors. Methods The retrospective analysis was performed on 85 patients undergoing the limb salvage operation with prosthetic replacement for tumors from January 1994 to December 2004. Ofthe patients, 21 (13 males and 8 females, aged 18-58 years) underwent reoperations for various reasons. All the diagnoses were pathologically confirmed(10 patients with osteosarcoma, 4 with chondrosarcoma, 5 with giant cell tumor of the bone, 2 with osteofibrosarcoma). The distal femur was involved in 9 patients, proximal tibia in 8, proximal femur in 2, proximal humerus in 1, and acetabulum in 1. According to the Enneking surgical grading system, there were 5 patients in ⅠB and 16 in ⅡB. The time between the first operation and the reoperation was 2 weeks to 20 years. The common reasons for the reoperation were tumor recurrence in 8 patients, prosthetic loosening in 5, no healing of the incision in4,joint dislocation in 3, and implant fracture in 1. The amputation and the prosthesis revision were respectively performed on 6 patients, extensive resection ofthe tumor on 3, the myo-skin flap translocation on 4, internal hemipelvectomy without reconstruction on 1, and open reduction on 1.Results The follow-up in18 patients for 1-5 years (average, 3 years and 4 months) revealed that 4 patients died of osteosarcoma with pulmonary metastasis. The other 14 patients had no tumor recurrence or loosening of the prosthesis, and the incisions healed well. The assessment on the joint function was performed on 13 of the 18 patients and the results were as follows: excellent in 2 patients, good in 5, fair in 4, and poor in 2, with a satisfaction rate of the reoperation with limb salvage of 84.6%and an excellent-good rate of 53.8%. Conclusion Tumor recurrence is the most common reason for the reoperation after the limb salvage with prosthesis for tumors, and loosening of the prosthesis is an important reason, too. By therules of the bone tumor limb savage, the limb salvage operations can also beperformed, which can achieve a satisfactory result of the limb function.
Objective To summary the operative technique of liver retransplantation （RLT）. Methods The clinical data of 62 cases who had received RLT in our institute from Jan. 2003 to Jun. 2012 were analyzed retrospectively， and the experience about RLT was summaried too. Results The operative time 〔（12.7±3.5） h vs. （10.5±3.0） h〕， bleeding volume （3 431 mL vs. 2 211 mL）， and blood volume transfused during operation （3 229 mL vs. 1 910 mL） in 62 cases who had underwent RLT were longer or higher than that of 38 patients who had underwent the first liver transplantation （LT） in our hospital （P＜0.05）， but there was no significant difference on the model for end-stage liver disease （MELD） score between the 2 groups （P＞0.05）. All cases were followed up for 1-104 months （average 31 months）. Twenty case died within 1 month after RLT， including sever lung or abdominal infection in 13 cases， multiple organ failure in 4 cases， hepatic artery complication in 2 cases， and portal vein complication in 1 case. Eight cases died of tumor recu-rrence during 14-69 months （average 27 months） after RLT. The cumulative survival rate of 1-， 2-， and 5-year of 62 cases of RLT were 67.7%， 59.7%， and 56.4%， respectively. The 34 patients had survived for 3-104 months （average 49 months）， of them， there were biliary stenosis in 3 cases who were cured by interventional radiology treatment， biliary stenosis in 2 cases who were cured by a third RLT， infection in 10 cases who were cured by anti-infective therapy and immunosuppressant adjustment， light rejection in 2 cases who were relieved by dosage increase of oral immunosuppressant， other 17 cases suffered no complications and all in good condition. Conclusions RLT is an effective method for irreversible graft failure after LT. Proper surgical procedure contributes to the increase of survival rate of patients who has received RLT.
Objective To summary the clinical experience of liver retransplantation （RLT）， and to improve the effect. Methods The clinical data of 62 cases who had received RLT in our institute from Jan. 2003 to Jun. 2012 were analyzed retrospectively. The survival rates of patients with different interval between two liver transplantation （LT） were calculated， and the data of patients who died and survived during perioperative period after operation were compared and analyzed. Results The 1-， 2-， and 5-year cumulative survival rates of 62 patients were 67.7%， 59.7%， and 56.4%， of early stage RLT patients were 38.5%， 38.5%， and 30.8%， of later stage RLT patients were 75.5%， 65.3%， and 63.3%， respectively. There were 28 patients died after operation， and 20 patients （71.4%） died during perioperative period， whose major cause of death were infection （65.0%， 13/20）， in addition， 4 cases （20.0%） died of multiple organ failure， 2 cased （10.0%） died of hepatic artery complication， 1 case （5.0%） died of portal vein complication. Eight cases （28.6%） died after perioperative period in reason of tumor recurrence. The model for end-stage liver disease （MELD） score 〔（26.95±9.28） score vs. （14.23±9.06） score〕， creatinine （Cr） level 〔（157.3±88.0） μmol/L vs.（69.8±35.9） μmol/L〕， international normalized ratio （INR） value 〔（1.676±0.744） vs.（1.124±0.286）〕， and total bilirubin （TBiL） value 〔431.8 μmol/L vs. 248.2 μmol/L〕 of patients died during perioperative period were higher than that of patients survived after perioperative period （P＜0.05）. The ratio of abnormal Cr of patients died during perioperativeperiod and survived after perioperative period were 60.0% （12/20） and 7.1% （3/42）， respectively. The 34 patients who had survived after perioperative period were all got followed-up for 3-104 months （average 49 months）. There were no tumor recurrence during the followed-up， and liver function of them were normal. Conclusions RLT is an effective method for irreversible graft failure after LT. Optimum operative time and reasonable individual immunosuppressive regimen to decrease the infection rate are all contribute to the increase of the survival rate.
Objective To explore the reoperative techniques of differentiated thyroid carcinoma. Methods Clinical data of 56 patients who treated in The First Affiliated Hospital of General Hospital of PLA and General Hospital of PLA from Feb. 2011 to Feb. 2013 were analyzed retrospectively. Results All performed surgeries were successful. Surgeries took 90-150 minutes with an average of 120 minutes. Bleeding during surgeries was 70-200 mL with an average of 120 mL. Postoperative drainage was 90-210 mL with an average of 100 mL. The pathological diagnosis of the second surgery in 44 cases were as the same as the first， but there were no malignant tumor tissues of dissected glands in 12 cases. All patients had no postoperative bleeding and bucking， but 8 patients experienced hand and foot numbness， and 5 patientsexperienced transient hoarseness. Fifty patients were followed-up for 6-30 months （average 10.8 months） from the reoper-taion and 18-66 months （average 45.2 months） from the first operation， and rate of postoperative followed-up was 89.3%（50/56）. During the followed-up， 1 patient with papillary thyroid carcinoma and 1 patient with follicular thyroid carcinoma died in 44 months and 38 months respectively， 3 patients suffered lymph node metastasis at non-Ⅵ region ofaffected side， no one suffered recurrence. Conclusions For differentiated thyroid carcinoma patients who are undergoingthe second surgery， thorough whole body condition analysis should be performed and appropriate type of surgery should be chosen. By using recurrent laryngeal nerve monitoring， carbon nanoparticles for lymph node clearance， and protecting parathyroid gland to lower the possibility of postoperative complication， to improve survival rate and life quality.
Objective To discuss the resection extent of primary surgery for papillary thyroid carcinoma （PTC） based on the analysis of the remaining thyroid gland residue and lymph nodes metastasis. Methods The clinical data of 163 patients with PTC received reoperation from January 2009 to September 2011 in our hospital were analyzed retrospectively. Results There were 24 males and 139 females in these patients. The age was 10-75 years old with （38.22±14.57） years old. Among 131 patients received residual thyroid thyroidectomy，88 patients were below 45 years old，and the cancer residual rate was 60.23% （53/88）；the others were over 45 years old，and the cancer residual rate was 76.74% （33/43），which was no significant difference （P?=?0.062）.The lymph nodes metastasis rate was 77.14% （81/105） in the patients below 45 years old and 81.13%?（43/53） in the patients over 45 years old among 158 patients received cervical lymph nodes dissection，which was no significant difference （P?=?0.958）.The cancer residual rate was 74.36%?（58/78），53.66%?（22/41），50.00%?（6/12），and 0 （0/32） in the patients with the tissue less than one lobe resection，lateral lobe （isthmus） resection，lateral lobe plus opposite side subtotal resection，total or subtotal resection，respectively. The total cancer residual rate was 65.65% （86/131） and the bilateral cancer residual rate was 52.76%?（86/163） after reoperation.79.75%?（130/163） of the patients didn’t received lymph nodes dissection in the primary surgery. The lymph nodes metastasis rate was 71.21%?（94/132） and 80.58% （83/103） in the reoperation patients received central region lymph nodes dissection and cervical lateral lymph nodes dissection, respectively. Conclusions Multifocus is an obvious character of PTC. Patients over 45 years old have more opportunities of tumor residual than that of the youngers （below 45 years old），but the result was no statistic value. For the most patients with PTC，a smaller resection extent suggests a larger risk for cancer residual，and total thyroidectomy or subtotal thyroidectomy leads to the least possibility for the risk. Cervical lymph node is a major type for its metastasis. Proper lymph nodes dissection is an essential way to reduce recurrence and reoperation. The Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer （2009） could be a best choice for therapy of PTC. And it is proposed to take central region lymph nodes dissection during primary surgery.