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Ann Thorac Surg 2006;82:586-591
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Reduction Ascending Aortoplasty: Midterm Follow-Up and Predictors of Redilatation

Gianluca Polvani, MDa, Fabio Barili, MDa,*, Luca Dainese, MDa, Veli K. Topkara, MDb, Faisal H. Cheema, MDb, Eleonora Penza, MDa, Sandro Ferrarese, MDc, Alessandro Parolari, MD, PhDa, Francesco Alamanni, MDa, Paolo Biglioli, MDa

a Department of Cardiovascular Surgery, Centro Cardiologico Monzino, University of Milan, Milan, Italy
b Division of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University–New York Presbyterian Hospital, New York, New York
c Department of Cardiac Surgery–University of Insubria, Ospedale di Circolo "Fondazione Macchi," Varese, Italy

Accepted for publication March 13, 2006.

* Address correspondence to Dr Barili, Department of Cardiac Surgery–University of Milan, Centro Cardiologico Monzino IRCCS, Via Parea 4, 20138 Milan, Italy (Email: fabarili{at}libero.it).


This article has been selected for the open discussion forum on the CTSNet Web Site: http://www.ctsnet.org/sections/newsandviews/discussions/index.html

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 The Society of Thoracic...
 Acknowledgments
 References
 
BACKGROUND: Reduction ascending aortoplasty is an alternative procedure to the replacement of the ascending aorta in case of ascending aorta aneurysm without aortic root involvement. This study was designed to evaluate the midterm follow-up of aortoplasty and to determine predictors of redilatation.

METHODS: From January 1, 1998, to April 30, 2005, 68 patients with dilatation of the ascending aorta underwent unsupported reduction aortoplasty in combination with other cardiac procedures. All patients underwent associated surgical procedures. Sixty patients (88.2%) underwent associated aortic valve replacement. Cumulative follow-up time was 191.4 patient-years and was 100% complete. Median follow-up time was 2.5 years, and mean follow-up time was 2.9 ± 1.7 years (range, 0.4 to 6.3 years).

RESULTS: The overall perioperative mortality rate was 1.5%. Overall survival estimates at 3 and 6 years were 93.3% ± 4.5% and 89.3% ± 5.9%, respectively. The actuarial freedom from cardiac-related death at 3 and 6 years was 100% and 95.7% ± 4.3%, respectively. Ascending aorta redilatation occurred in 5 patients (7.5%). The actuarial freedom from redilatation at 3 and 6 years was 97.7% ± 2.3% and 79.8% ± 8.4%, respectively. The actuarial freedom from reoperation at 3 and 6 years was 100% and 86.3% ± 7.5%, respectively. Only preoperative diameter was a significant predictor of redilatation using multivariate stepwise logistic regression analysis.

CONCLUSIONS: Unsupported reduction aortoplasty is a safe and effective technique with low mortality, low morbidity, and rare late complications for selected chronic aneurysm of the ascending aorta with diameter less than 55 mm.

A variety of different surgical techniques are currently available for the treatment of ascending aortic aneurysm. The choice of the appropriate technique requires careful consideration of many factors, such as aneurysm morphology, the associated dilatation of the annulus or sinuses, the presence of aortic valve disease, and surgical risks [1].

When the dilatation involves only the ascending aorta, the most frequently performed procedure is the ascending aorta replacement, which is associated with eventual aortic valve replacement if there is concomitant valve disease. This procedure offers good results [2], but still entails significant risk, with both perioperative mortality and morbidity varying up to 10% [3–6].

Reduction ascending aortoplasty (RAA) is an alternative to the ascending aorta replacement in patients with an ascending aortic aneurysm without aortic root involvement [7]. It is a feasible technique that presents various advantages, such as being a less radical procedure than Dacron graft replacement, a shorter cross-clamp time, and less bleeding. Moreover, lower rates of mortality and morbidity have been reported with RAA than with alternative procedures [8, 9].

However, as a result of a reported high aneurysm recurrence rate, RAA is considered a controversial surgical option that is generally limited to select patients in whom high perioperative risks necessitate shorter cross-clamp time [10]. Reduction ascending aortoplasty is traditionally indicated in older patients with nondissecting borderline ascending aortic aneurysm and nondilated aortic root, especially during operation for other cardiac disease [1, 11, 12].

Different types of RAA are described and can be supplemented with circumferential external reinforcement using synthetic materials [6]. In our institute, we performed the procedure described by Robicsek and coworkers [6, 7] without external reinforcement. This study was designed to evaluate the midterm follow-up of unsupported RAA and to determine predictors of redilatation.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 The Society of Thoracic...
 Acknowledgments
 References
 
From January 1, 1998, to April 30, 2005, 68 patients with ascending aortic dilatation underwent reduction aortoplasty alone or in combination with other cardiac procedures. Data were collected prospectively and patients were followed up at regular (6 months) intervals. This study had the approval of our institutional ethics committee, and written informed consent was obtained from every patient by the senior investigator in accordance with institutional guidelines.

Aortoplasty was performed when patients presented with moderate ascending aorta dilatation, with aortic diameters between 40 and 50 mm for younger patients and aortic diameters of up to 60 mm for older patients or in patients for whom it was believed that reducing cross-clamp and perfusion times would be beneficial owing to coexisting diseases. In the event of aortic diameters greater than 60 mm, aortoplasty was considered only when operative risk was very high.

Clinical variables are detailed in Table 1. The mean age was 61.9 ± 12.3 years (median, 64.5 years; range, 22 to 78 years). Forty-one patients were male (60.3%), and 92.7% of patients were in New York Heart Association functional class II or III.


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  		Table 1. Preoperative Characteristics
 
We performed a preoperative echocardiography and a computed tomographic scan of the chest to evaluate the diameter of the ascending aorta in all patients. Aneurysm diameter was measured at the level of bifurcation of the pulmonary artery. The mean preoperative aortic diameter was 50.9 ± 7.0 mm (range, 39 to 70 mm). None of the patients had Marfan syndrome or other genetic disorders, as aortoplasty is contraindicated in such patients. Aortic dilatation was fusiform in all patients and localized to the ascending aorta without involving the aortic root or arch.

Aortic valve disease was present in 60 patients (88.2%). The valvular pathologic diagnosis was aortic stenosis in 21 patients (30.9%), aortic insufficiency in 23 patients (33.8%), and mixed lesion in 6 patients (8.8%). Ten patients (14.7%) had diseased bicuspid aortic valve. Three patients (4.4%) had previously undergone aortic valve replacement with mechanical valves. No patient had aortic root dilatation. All but 2 patients had good ventricular function. 59 patients (86.8%) had left ventricular ejection fraction greater than 0.50, 7 patients (10.3%) had left ventricular ejection fraction between 0.40 and 0.50, 2 patients (2.9%) had left ventricular ejection fraction less than 0.40. Cardiac catheterizations and coronary angiographies were performed in all patients 40 years or older. There was significant coronary artery disease in 11 cases (16.1%).

All patients underwent associated surgical procedures. Sixty patients (88.2%) underwent associated aortic valve replacement, whereas other concomitant procedures included coronary artery bypass grafting in 11 patients (16.1%), mitral valve replacement in 3 (4.4%), and mitral valve repair in 3 (4.4%).

Surgical Technique
Median sternotomy, cardiopulmonary bypass, moderate hypothermia (30°C), and aortic cross-clamping were used in all patients. The aortic cannula was placed in the proximal transverse aortic arch in all but 3 patients. A right femoral arterial cannula was used in patients with previous aortic valve replacement. Cardiac arrest was obtained by an initial bolus of anterograde cold crystalloid cardioplegic solution (only in patients with aortic valve stenosis), followed by a bolus of retrograde cold crystalloid cardioplegic solution and maintained by retrograde cardioplegia repeated at 20-minute intervals, with additional topical cooling. The aortic incision was extended from the noncoronary sinus following an upper left line along the aortic axis to the aortic arch bend just proximal to the aortic cross-clamp.

Reduction aortoplasty consisted of direct resection of an oval portion of the anterior aortic wall to bring the diameter of the ascending aorta down to normal. The expected supraaortic ridge was computed with Roman's formula [13]. Once the ideal aortic diameter was reached, we established a tail about 3 cm of circumference per 1 cm of diameter to reduce, given that the circumference is 2{pi}r (r = radius; {pi} = 3.14). The aortotomy was then closed in two layers using 4-0 suture [9]. The aortoplasty was not additionally supported by wrapping the ascending aorta with a prosthetic graft.

All the associated cardiac procedures were performed after the incision of the aorta and before the aortoplasty. The mean aortic cross-clamp time was 68.2 ± 8.1 minutes, and the mean duration of cardiopulmonary bypass was 77.3 ± 13.2 minutes. Table 2 summarizes the surgical operations and operative data. Intraoperative transesophageal echocardiography was performed on every patient before and after reduction aortoplasty.


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  		Table 2. Operative and Perioperative Details
 
Patient Follow-Up
Data were obtained by means of direct visits and telephone interviews. Transthoracic echocardiography or computed tomographic scan of the chest was performed preoperatively, at discharge, at 3 months, at 1 year, and annually thereafter. Follow-up of survivors was last collected between May 15 and May 28, 2005. Cumulative follow-up time was 191.4 patient-years and was 100% complete. Median follow-up time was 2.5 years, and mean follow-up time was 2.9 ± 1.7 years (range, 0.4 to 6.3 years).

Statistical Analysis
Continuous variables were expressed as mean ± standard deviation. Discrete variables were expressed as numbers and proportions. Actuarial life table estimates were constructed using the Kaplan–Meier method. Repeated-measures analysis of variance was used to detect any significant changes in mean ascending aortic diameter with time. If statistically significant, Student's paired t test was then performed, with Bonferroni's method used to correct for multiple comparisons.

Significant predictors of redilatation were investigated by examining the association between various variables and redilatation in univariate analysis, followed by a stepwise logistic regression analysis on factors demonstrated to be significant in univariate analysis. For univariate and multivariate analysis, only patients with a follow-up greater than 12 months (58 patients) were included, as dilatation generally does not occur in the first months after surgery. A p value of less than 0.05 was considered statistically significant. Statistical analyses were performed using SPSS 13.0 software (SPSS, Inc, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 The Society of Thoracic...
 Acknowledgments
 References
 
Postoperative and Perioperative Mortality and Morbidity
There was one in-hospital death. The cause of death was acute anterograde dissection of the aortic arch that occurred 5 days after surgery. The overall perioperative (30-day) mortality rate was 1.5%. No other patient experienced significant postoperative complications. The total perioperative morbidity rate was 1.5%.

Long-Term Survival
There were 3 late deaths at the time of follow-up. Overall survival estimates at 3 and 6 years were 93.3% ± 4.5% and 89.3% ± 5.9%, respectively (Fig 1). The mean age at death was 76.1 ±70 years.


Figure 1
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  		Fig 1. The actuarial freedom from death (solid line, *) and the actuarial freedom from cardiac-related death (dashed line, {blacksquare}).

 
There was one cardiac-related death, with stroke as the cause of death. The actuarial freedom from cardiac-related death at 3 and 6 years was 100% and 95.7% ± 4.3%, respectively (Fig 1). There were 2 noncardiac deaths, attributed to lung cancer and prostate cancer. The actuarial freedom from noncardiac death at 3 and 6 years was 93.3% ± 4.5% and 93.3% ± 4.5%, respectively.

Ascending Aortic Redilatation and Reoperation
Ascending aorta redilatation occurred in 5 patients (7.5%) after 21, 38, 38, 46, and 52 months. The actuarial freedom from redilatation at 3 and 6 years was 97.7% ± 2.3% and 79.8% ± 8.4%, respectively (Fig 2). The mean diameter of the redilated aorta was 50.8 ± 4.6 mm. All patients who experienced redilatation had a preoperative original diameter greater than 55 mm (56, 56, 58, 64, and 70 mm). Original dilatation was associated with aortic stenosis in 2 patients, aortic insufficiency in 2, and bicuspid valve in 1.


Figure 2
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  		Fig 2. The actuarial freedom from redilatation (solid line, *) and the actuarial freedom from reoperation (dashed line, {blacksquare}).

 
Three patients underwent ascending aortic replacement with Dacron graft. All 3 patients survived reoperation uneventfully. In the other 2 cases, it was decided not to proceed because of the stability of the ascending aorta dilatation and patients' advanced age. The actuarial freedom from reoperation at 3 and 6 years was 100% and 86.3% ± 7.5%, respectively (Fig 2).

The ascending aorta diameters are summarized in Table 3. As shown, the mean diameter decreased significantly after surgery without further changes.


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  		Table 3. Changes in Mean Ascending Aorta Diameters a
 
Predictors of Redilatation
Table 4 outlines variables that were evaluated for their impact on redilatation using univariate analysis. The only significant risk factor adversely affecting redilatation was preoperative diameter. Although not significant, the p value for postoperative ascending aorta diameter was near to significance (p = 0.074) and was included in the multivariate analysis.


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  		Table 4. Univariate Analysis of Variables Affecting Redilatation
 
Only preoperative diameter was a significant predictor of redilatation using multivariate stepwise logistic regression analysis (Table 5).


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  		Table 5. Factors Affecting Redilatation Using Multivariate Stepwise Logistic Regression
 
The preoperative ascending aortic diameter was dichotomized using different cut-off values (45, 50, 55, or 60 mm) to determine which is the first to be an independent risk factor for redilatation in a logistic regression model. A preoperative diameter greater than 55 mm was found to be a predictor of redilatation (p = 0.304 for 45 mm; p = 0.148 for 50 mm; p = 0.009 for 55 mm; p = 0.023 for 60 mm). The odds ratio was 18.5 for preoperative aortic diameter greater than 55 mm.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
The Society of Thoracic...
 Acknowledgments
 References
 
Reduction ascending aortoplasty is a procedure for the treatment of ascending aortic aneurysm, and a viable alternative to radical ascending aortic replacement. It is generally indicated in patients with a borderline dilated aorta in which a decreased aortic cross-clamping time is advantageous [14]. Reduction ascending aortoplasty is effective in decreasing the aortic diameter with short cross-clamp times and low rates of mortality and morbidity [8, 9]. In our series, only 1 patient experienced a serious perioperative complication, dissection of the aortic arch, which led to death. All other patients experienced an uncomplicated postoperative course. The good perioperative outcomes of RAA contrasts with that of total ascending aortic replacement, which still remains a challenge, as reported by Robicsek and colleagues [6]. Ascending aortic replacement entails higher rates of perioperative mortality and morbidity [3, 4, 15–17], but could reflect differing situations and patient characteristics. Aortoplasty is not indicated in all patients who require an ascending aortic replacement, as patients with type A aortic dissection, Marfan syndrome, and cystic medial necrosis are generally contraindicated. However, reduction aortoplasty is generally performed in older patients with high perioperative risks and with other associated cardiac procedures.

The major concern about reduction aortoplasty is the long-term follow-up, with specific regard to survival and rate of redilatation. We pointed out an overall survival estimate at 6 years of 89.3% ± 5.9% and a freedom from cardiac-related death at 6 years of 95.7% ± 4.3%. Only 1 patient at 6 years' follow-up died of cardiac reasons whose cause of death was not related to reduction aortoplasty, as stroke was related to aortic valve replacement. These results are similar to those presented in other studies [8–10]. Bauer and associates [9] reported a survival at 5 years of 94%. They also reported freedom from aortoplasty-related mortalities, supporting the claim that reduction aortoplasty procedure does not affect midterm and long-term survival [8, 9].

Literature review regarding the occurrence of redilatation after RAA shows conflicting results, with rates varying from 0% to 25% [8–10, 18]. The absence of external reinforcement is claimed to be responsible for these differences, but direct comparison among studies is difficult owing to lack of homogeneous groups. Arsan and colleagues [8] reported concomitant aortic valve replacement in 35.5% of patients, without specifying the type of valve disease, whereas 88.9% of patients underwent combined aortic valve replacement in our group and 94.8% in the report of Bauer and associates [9]. In our study, the leading valvular disease was insufficiency (42.6%), whereas Bauer and coworkers [9] reported 22.6% of insufficiency and 47.8% of stenosis. Again, Muller and colleagues [10] reported that all redilatation occurred in patients with Marfan syndrome whereas other authors considered Marfan syndrome to be a contraindication to RAA [6, 8, 9]. We found an actuarial freedom from redilatation at 6 years of 79.8% ± 8.4%. Five patients had redilatation of the ascending aorta (7.5%). This result is similar to those of Bauer and colleagues [9] and Kamada and associates [18].

There is a general agreement that patients with ascending aortic aneurysm greater than 60 mm should not undergo reduction aortoplasty [6]. Univariate and multivariate analysis of our data confirmed that preoperative diameter is the main factor to be considered before performing RAA, as it is the only independent risk factor for redilatation. The risk of redilatation increased significantly for preoperative diameter greater than 55 mm (p = 0.001), with an odds ratio of 18.5. All patients who exhibited redilatation had a preoperative diameter greater than 55 mm. We agree with Kamada and coworkers [18] and advise that a diameter of 55 mm should be considered the cut-off.

Another important factor to avoid redilatation after RAA is the postoperative ascending aortic diameter. In our study, it was not identified as an independent risk factor for redilatation, even given a difference of postoperative diameter among patients who experienced redilatation and who did not approach significance (p = 0.078). This could reflect a dependent correlation between preoperative and postoperative diameters, as patients with greater preoperative diameter had greater postoperative diameter. Although not significant in our study, the postoperative diameter still remains an important concern, and it should be less than 35 mm to avoid redilatation [9].

No other risk factors were identified, including aortic valve insufficiency, which is reported to be a risk factor for redilatation after unsupported RAA [6]. However, an aortic prosthesis was implanted in all cases, which can favorably influence the outcomes by stabilizing the aortic orifice and facilitating proximal anchoring.

Limitations of the Study
This study is prospective by nature, but is not randomized. Aortoplasty was performed in a selected subgroup of patients with aneurysm of the ascending aorta. Information was not collected regarding aortic wall histology, and was not correlated to redilation. Moreover, long-term follow-up is needed to evaluate whether patients with a preoperative diameter less than 55 mm also can redilate, particularly with respect to this young group.

Conclusions
In our group, unsupported RAA resulted in a safe and effective technique with low mortality, low morbidity, and few late complications for selected chronic aneurysm of the ascending aorta with diameter less than 55 mm. It can represent an alternative to the replacement of the ascending aorta in selected patients with moderate dilatation. A diameter greater than 55 mm is an independent risk factor for redilatation, and it should be considered a contraindication to this procedure and may be considered an indication to the Dacron graft support.


   The Society of Thoracic Surgeons: Forty-Third Annual Meeting
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 Introduction
 Material and Methods
 Results
 Comment
 The Society of Thoracic...
Acknowledgments
 References
 
Please mark your calendars for the Forty-Third Annual Meeting of The Society of Thoracic Surgeons, to be held in San Diego, California, from January 29–31, 2007. The program will provide in-depth coverage of thoracic surgical topics selected to enhance and broaden the knowledge of cardiothoracic surgeons. Attendees will benefit from traditional Abstract Presentations, as well as Surgical Forums, Breakfast Sessions, Surgical Motion Pictures, and Town Hall Meetings on specific topics.

Advance registration forms, hotel reservation forms, and details regarding transportation arrangements, as well as the complete meeting program, will be mailed to Society members this fall. Also, complete meeting information will be available on the Society's Web site at www.sts.org. Nonmembers who wish to receive information on the Annual Meeting may contact the Society's secretary, Douglas E. Wood.

Abstracts for the meeting must be submitted electronically. The electronic submission form may be accessed at www.sts.org. There is no charge for submitting abstracts. The submission deadline is June 30, 2006 at 5:00 PM CDT. Please direct any questions regarding your submission to the Society's headquarters.

Douglas E. Wood, MD Secretary

The Society of Thoracic Surgeons

633 N. Saint Clair St, Suite 2320

Chicago, IL 60611-3658

Telephone: (312) 202-5800

Fax: (312) 202-5801

e-mail: sts{at}sts.org

website: www.sts.org


   Acknowledgments
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 Abstract
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 Material and Methods
 Results
 Comment
 The Society of Thoracic...
 Acknowledgments
References
 
We are grateful to Catherine Forster for her assistance in the preparation of this manuscript.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 The Society of Thoracic...
 Acknowledgments
 References
 

  1. Ergin MA, Spielvogel D, Apaydin A, et al. Surgical treatment of the dilated ascending aortawhen and how?. Ann Thorac Surg 1999;67:1834-1839.[Abstract/Free Full Text]
  2. De Paulis R, Cetrano E, Moscarelli M, et al. Effects of ascending aorta replacement on aortic root dilatation Eur J Cardiothorac Surg 2005;27:86-89.[Abstract/Free Full Text]
  3. Elefteriades JA. Natural history of thoracic aortic aneurysmsindications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002;74(Suppl):S1877-S1880.[Abstract/Free Full Text]
  4. Immer FF, Barmettler H, Berdat PA, et al. Effects of deep hypothermic circulatory arrest on outcome after resection of ascending aortic aneurysm Ann Thorac Surg 2002;74:422-425.[Abstract/Free Full Text]
  5. Jault F, Nataf P, Rama A, et al. Chronic disease of the ascending aorta. Surgical treatment and long-term results J Thorac Cardiovasc Surg 1994;108:747-754.[Abstract/Free Full Text]
  6. Robicsek F, Cook JW, Reames Sr MK, Skipper ER. Size reduction ascending aortoplastyis it dead or alive?. J Thorac Cardiovasc Surg 2004;128:562-570.[Abstract/Free Full Text]
  7. Robicsek F. A new method to treat fusiform aneurysm of the ascending aorta associated with aortic valve diseasean alternative to radical resection. Ann Thorac Surg 1982;34:92-94.[Abstract]
  8. Arsan S, Akgun S, Kurtoglu N, Yildirim T, Tekinsoy B. Reduction aortoplasty and external wrapping for moderately sized tubular ascending aortic aneurysm with concomitant operations Ann Thorac Surg 2004;78:858-861.[Abstract/Free Full Text]
  9. Bauer M, Pasic M, Schaffarzyk R, et al. Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve Ann Thorac Surg 2002;73:720-723.[Abstract/Free Full Text]
  10. Mueller XM, Tevaearai HT, Genton CY, et al. Drawback of aortoplasty for aneurysm of the ascending aorta associated with aortic valve disease Ann Thorac Surg 1997;63:762-766.[Abstract/Free Full Text]
  11. Baumgartner F, Omari B, Pak S, Ginzton L, Shapiro S, Milliken J. Reduction aortoplasty for moderately sized ascending aneurysms J Card Surg 1998;13:129-132.[Medline]
  12. Barnett MG, Fiore AC, Vaca KJ, Milligan TW, Barner HB. Tailoring aortoplasty for repair of fusiform ascending aortic aneurysms Ann Thorac Surg 1995;59:497-501.[Abstract/Free Full Text]
  13. Roman MJ, Devereux RB, Kramer-Fox R, O'Loughlin J. Two-dimensional echocardiographic aortic root dimensions in normal children and adults Am J Cardiol 1989;64:507-512.[Medline]
  14. Carrel T, von Segesser L, Jenni R, et al. Dealing with dilated ascending aorta during aortic valve replacementadvantages of conservative surgical approach. Eur J Cardiothorac Surg 1991;5:137-143.[Abstract]
  15. Yun KL, Miller DC, Fann JI, et al. Composite valve graft versus separate aortic valve and ascending aortic replacementis there still a role for the separate procedure?. Circulation 1997;96(Suppl 2):368-375.
  16. Beddermann C, Norman JC, Cooley DA. Combined replacement of the ascending aorta and the aortic valve in 42 consecutive patientsa comparison of composite graft techniques and conventional techniques over one year. Cardiovasc Dis 1980;7:214-229.[Medline]
  17. Malashenkov AI, Rusanov NI, Muratov RM, et al. Eight years clinical experience with the replacement of the ascending aorta using composite xenopericardial conduit Eur J Cardiothorac Surg 2000;18:168-173.[Abstract/Free Full Text]
  18. Kamada T, Imanaka K, Ohuchi H, et al. Mid-term results of aortoplasty for dilated ascending aorta associated with aortic valve disease Ann Thorac Cardiovasc Surg 2003;9:253-256.[Medline]



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