Search

Renal cell carcinomas (RCCs) represent 2-3% of cancer cases in Denmark, with increasing incidence. RCCs invading the inferior vena cava (IVC) with tumour thrombus (TT) are associated with poor prognosis. Classification is based on tumour extent in the IVC. Surgical treatment involves radical nephrectomy and thrombectomy, with different approaches depending on TT level. Complications are significant, with a mortality rate of 2-13%. Additional therapies may improve outcomes. This review finds that all patients with RCC and IVC TT should be considered for surgery., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Background: The optimal medical strategy for prevention of thromboembolic events after surgical bioprosthetic aortic valve replacement (BAVR) is still debated. The objective of this study was to compare warfarin therapy (target INR of 2.0 to 3.0) with aspirin 150mg daily as antithrombotic therapy for the first three months after BAVR with or without concomitant coronary artery bypass grafting (CABG). The aim was to evaluate thromboembolic complications, major bleeding complications and death., Materials and Methods: Prospective, single-centre, open-label, randomized controlled trial. 370 patients were enrolled, 328 were available for data analysis., Results: At baseline the warfarin and aspirin groups were comparable. Thromboembolic events were comparable between groups 11 (6.6%) vs. 12 (7.5%), p=0.83. Major bleeding events occurred numerically more often in warfarin patients 9 (5.4%) vs. 3 (1.9%), p=0.14. Warfarin was in multivariate analysis significantly associated with major bleeding OR 5.18 (CI 1.06-25.43), p=0.043. 90-day mortality was comparable between groups 8 (4.7%) vs. 6 (3.7%), p=0.79., Conclusions: Our results suggest that aspirin might be equally effective as warfarin in preventing thromboembolic events after BAVR, but with less major bleedings. Although this is numerically the largest trial testing this hypothesis in a prospective randomized trial, further adequately powered studies are warranted., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To investigate relations between chest pain after coronary artery bypass grafting (CABG), quality of life (QoL), and coping capacity., Design: Two groups were included, Group I (n = 111) was evaluated before and 1 year postoperatively, and Group II (n = 102) once, at 3 years. The questionnaire included parts of the Seattle angina questionnaire, one question concerning chest pain, coping capacity (sense of coherence), emotional state, the Psychological general well-being index, and a global QoL question., Results: Chest pain was significantly related to lower coping capacity (at 1 year) and lower QoL scores (at 1 and 3 years). Changes of coping capacity and emotional state from before to 1 year after the CABG did not reach statistical significance in the chest pain group while the no chest pain patients had significantly better emotional state. The relation between chest pain and worse QoL was significantly reduced by high coping capacity., Conclusion: Independent of the direction of causality, the patient's coping capacity and experienced chest pain is highly related.

Study Objectives: Perioperative myocardial infarction (PMI) during coronary artery bypass grafting (CABG) is an important clinical problem because it is closely associated with increased morbidity and mortality. The diagnosis of PMI is, however, associated with several problems. Due to the surgical trauma, the usual indicators of myocardial infarction (pain, ECG changes, and elevated biochemical markers of infarction) have uncertain diagnostic value. The primary aim of this study was to illustrate the levels of the biochemical markers after uncomplicated bypass surgery defined as no clinical or ECG evidence of PMI, and no graft occlusion at 7 days by repeat angiography; and secondarily, to establish biochemical diagnostic discrimination limits for detection of in-hospital graft occlusion., Methods and Results: One hundred three patients undergoing elective CABG were closely monitored by serial measurements of creatine kinase (CK)-MB mass, myoglobin, troponin T, and troponin I, and underwent a repeat angiography before discharge. Seven patients had ECG evidence of PMI. Peak troponin T and CK-MB values were significantly higher in these seven patients, although the diagnostic performances of the optimally chosen cutoff levels for diagnosing AMI were fair. Twelve patients had at least one occluded graft shown by repeat angiography. Peak values of CK-MB and troponin T were significantly higher in patients with graft occlusion (52.2 microg/L vs 24.7 microg/L, p = 0.01; and 3.7 microg/L vs 1.0 microg/L, p = 0.05, respectively). By multivariate analysis, a diagnostic discrimination level of 30 microg/L for CK-MB did not reach statistical significance; however, the independent diagnostic value of a cutoff level for troponin T at 3 microg/L reached a level of significance (p = 0.06)., Discussion: We have suggested normal values of four different biochemical markers of infarction after uncomplicated coronary bypass surgery. Patients with in-hospital graft occlusion had higher peak CK-MB and troponin T values. However, the overlap with patients without graft occlusion is substantial, and the patency status in the individual cannot be reliably predicted from these noninvasive tests.

Objective: We examined the effects of aprotinin on graft patency, prevalence of myocardial infarction, and blood loss in patients undergoing primary coronary surgery with cardiopulmonary bypass., Methods: Patients from 13 international sites were randomized to receive intraoperative aprotinin (n = 436) or placebo (n = 434). Graft angiography was obtained a mean of 10.8 days after the operation. Electrocardiograms, cardiac enzymes, and blood loss and replacement were evaluated., Results: In 796 assessable patients, aprotinin reduced thoracic drainage volume by 43% (P < .0001) and requirement for red blood cell administration by 49% (P < .0001). Among 703 patients with assessable saphenous vein grafts, occlusions occurred in 15.4% of aprotinin-treated patients and 10.9% of patients receiving placebo (P = .03). After we had adjusted for risk factors associated with vein graft occlusion, the aprotinin versus placebo risk ratio decreased from 1.7 to 1.05 (90% confidence interval, 0.6 to 1.8). These factors included female gender, lack of prior aspirin therapy, small and poor distal vessel quality, and possibly use of aprotinin-treated blood as excised vein perfusate. At United States sites, patients had characteristics more favorable for graft patency, and occlusions occurred in 9.4% of the aprotinin group and 9.5% of the placebo group (P = .72). At Danish and Israeli sites, where patients had more adverse characteristics, occlusions occurred in 23.0% of aprotinin- and 12.4% of placebo-treated patients (P = .01). Aprotinin did not affect the occurrence of myocardial infarction (aprotinin: 2.9%; placebo: 3.8%) or mortality (aprotinin: 1.4%; placebo: 1.6%)., Conclusions: In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.

En-bloc double lung transplantation with tracheal anastomosis and direct revascularization of the bronchial arteries to the left internal mammary artery has been carried out in Denmark since June 1992. Forty-seven patients (32 with alfa-1 antitrypsin deficiency, 11 with chronic obstructive pulmonary disease, two with cystic fibrosis and two with primary pulmonary hypertension), 25 men and 22 women, average age 39 years (17-64 years), have received their first double-lung transplant with bronchial artery revascularization. Arteriography of the internal mammary artery and bronchial arteries was performed in 42 (89%) of the patients from 1-150 days after the operation. Successful bronchial artery revascularization was demonstrated arteriographically in 40 patients, in two patients the arteriography failed to show bronchial artery revascularization. Arteriography was not performed in five patients due to early complications and death. Bronchoscopy showed rapid, uncomplicated airway healing in 42 patients. Mucosal necrosis under the tracheal anastomosis was found in three patients, and severe obstructive endobronchial growth of the fungus Aspergillus fumigatus was diagnosed in the last two patients. The one- and two-year survival is 83% (Kaplan-Meier). Eleven patients are dead, five due to pulmonary causes and six due to extra-pulmonary causes. Pulmonary function became normal in nearly all surviving patients between three to six months after the transplantation. In conclusion, en-bloc double-lung transplantation with bronchial artery vascularization has shown good short-term results, and the one- and two-year survival gives hope that a successful bronchial artery revascularization will improve the long-term survival following lung transplantation.

Background: Lung transplantation including direct bronchial artery revascularization (BAR) has produced promising early results in small clinical series., Methods: In Copenhagen primary en bloc double lung transplantation with BAR, with the left mammary artery used as conduit, has been performed in 47 patients from 1992 to the end of 1995. After introduction of the bloc into the recipient, the mammary-to-bronchial artery anastomosis is performed as the first anastomosis, allowing perfect exposure and early reperfusion. Internal mammary-bronchial artery arteriography has been performed routinely after operation., Results: Bronchoscopic examination performed in all patients documented normal airway healing in 42, disturbed in two, and complicated in three. Arteriography performed in 42 patients demonstrated complete BAR in 25, incomplete in 15, and failed BAR in 2. Failed BAR was associated with complicated airway healing. The 1- and 2-year survival rate (Kaplan-Meyer) is 83%. Eleven patients have died, only one within 30 days. The total incidence of bronchiolitis obliterans syndrome at 3 years (with Kaplan-Meier technique) is 33%. Successful BAR has also been performed with an adjusted technique in a limited number of heart-lung and single lung transplantations. Our total experience of BAR in any type of lung transplantation includes 65 patients with an arteriographic BAR success rate of 94% (50 of 53 examined patients)., Conclusions: Experience has improved the surgical technique and has made BAR reliable and safe, be it double lung, single lung, or heart-lung transplantation. Early results are good, but only follow-up will show if long-term results after lung transplantation will be improved by BAR. Already today, en bloc double lung transplantation with BAR is a viable alternative to sequential bilateral lung transplantation.

During 1993-95 1000 consecutive patients were admitted for coronary bypass surgery. The total 30-day mortality of 1.9% was 0.9% for elective cases, 0.8% for reoperations and 0.2% for urgent cases. Perioperative myocardial infarction occurred in 44 patients of whom 25% had infarction at the start of the operation. Respiratory insufficiency occurred in 1.4% of the patients, 3.6% developed renal insufficiency and 1.8% had neurological defects postoperatively. Reoperation for bleeding occurred in 6%, and 0.2% developed sternal or mediastinal infection. This study demonstrates that the results of coronary bypass surgery at Rigshospitalet, Copenhagen are fully comparable to similar results in our neighbouring countries. The results can probably be further improved by more intensive treatment of perioperative ischaemia, especially in reoperations and urgent cases.

Thirty-six heart-lung and lung transplantations have been performed in Denmark from January 1992 to January 1994. Heart-lung transplantations was initially carried out in patients with pulmonary vascular diseases. Single lung, double lung and heart-lung transplantation have become therapeutical alternatives and the indications have been expanded to terminal patients with pulmonary diseases. Careful selection of patients and donors, careful surgical techniques and a stringent immunosuppressive treatment have minimized the perioperative mortality. Daily lung function measurements, transbronchial biopsies and bronchoalveolar lavage have created possibilities for an early and safe diagnosis of infections and rejections. A high frequency of obliterative bronchiolitis with loss of pulmonary function is still a serious and unsolved problem. Intensive investigations with the aim of understanding, preventing and treating obliterative bronchiolitis are going on.

Replacement of the aortic valve, root and ascending aorta with the technique first described by Cabrol was performed on 17 patients. In five cases the aortic arch was also replaced. The indications were type A aortic dissection with aortic insufficiency (8 cases, with acute dissection in 7), native endocarditis with severe aortic insufficiency and aortic root abscess (3 cases), prosthetic endocarditis (3), and true aneurysm of the ascending aorta with aortic insufficiency (3). Acute surgery was performed in 15 cases (88%). The overall operative mortality was 41%. For the patients discharged from hospital the mean observation time was 30 months. None died, but in one case the right leg of the interposition graft became occluded and reoperation was required 40 months after the primary operation for acute type A dissection. The described technique of aortic valve and root displacement can be used in all cases in which use of a composite graft is indicated, except in situations where the coronary ostia and arteries are damaged by acute dissection.

Fibrin tissue adhesive is a tissue adhesive in which the two components are fibrinogen concentrate and a thrombin solution, respectively. In autologous fibrin tissue adhesive, the fibrinogen is prepared from the patient's own blood in contrast to the fibrin adhesive available commercially where the fibrinogen is prepared from pooled donor plasma. In 42 heart and lung operations, autologous fibrin tissue adhesive prepared by a new method was employed in which the fibrinogen is separated from the patient's own plasma by precipitation with ethanol. Either 44 or 88 ml blood was employed for concentration of the fibrinogen. This resulted in 2.5 ml and 4.9 ml fibrinogen concentrate which was mixed with 0.3 parts of thrombin solution containing calcium and aprotinin (fibrolysis inhibitor) so that the total volumes of tissue adhesive were 3.3 ml and 6.4 ml. Production of autologous fibrin tissue adhesive is uncomplicated and takes less than 90 minutes. A new method of production of autologous tissue adhesive based on ethanol is described. The fibrin tissue adhesive prepared in this manner has a high concentration of fibrinogen and is effective as a haemostatic and as an adhesive in surgical operations and it has the further advantage that it is not associated with the risk of transmission of viral or for immunological reactions.

When the criterion of brain-death was introduced in Denmark on 1.7.1990, the possibility for heart transplantation and other interventions was opened. The first heart transplantation was carried out 3.10.1990 and, during the first year, 28 transplantations were carried out on 27 patients. The therapeutic routines in the department are reviewed and the results obtained after the first year are presented. A total of 33 donors who fulfilled the donor criteria were available. Of these, 28 came to Rigshospitalet, two were sent abroad and suitable recipients could not be found for two. The recipient group consisted of four women and 23 men with an average of 46 years. At the time of writing, on an average 169 days after operation (13-330), 23 out of 27 patients survived in good health and with normal cardiac function. Three patients are still in hospital.

In 209 patients referred with the diagnosis of tumour of the breast, the patient delay (PD) was registered together with the demographic and clinical conditions concerning the patient according to a meticulous questionnaire. In addition, the histological diagnosis and possible regional spread were registered. A total of 126 patients (60%) sought advice within one month of the commencement of symptoms. No statistically significant connection could be demonstrated between PD and age, marital status, education and occupational situation. No significant connection could be demonstrated between the size of the tumour, time of seeking advice and PD. A total of 115 patients (55%) had malignant tumours. The frequency of regional spread was found to be significantly greater in patients with PD longer than four weeks. Regular self-examination of the breast was undertaken by 92 (46%) of the patients and this was significantly more frequent in married or cohabiting patients, in patients with long education and in patients with employment outside the home. It did not prove possible to demonstrate briefer PD, lesser size of tumour and fewer cases of regional spread in patients who undertook self-examination of the breast but further research is required here.