What Is Minimally Invasive Cardiac Surgery?

Most patient concerns and demands for less invasive surgery are focused on comfort, cosmesis, and rehabilitation that are all related to the degree of invasiveness. The degree of invasiveness of cardiac surgery depends on two factors: the surgical approach--the length of the skin incision, the degree of retraction and aggression to the tissue, and the loss of blood--and the use of cardiopulmonary bypass. Regarding the surgical strategy, four categories of less invasive cardiac surgery can be distinguished: (1) direct coronary artery surgery via sternotomy on the beating heart (without extracorporeal circulation); (2) limited or modified approaches using conventional techniques and instruments with either conventional cardiopulmonary bypass or the EndoCPB endovascular cardiopulmonary bypass system; (3) minimally invasive direct coronary artery bypass on the beating heart via a parasternal or left anterior small thoracotomy; and (4) true Port-Access surgery in which all surgical acts are performed through ports and the heart is arrested with the Endoaortic Clamp catheter. These categories offer different advantages in terms of reducing invasiveness and may have different learning curves. Minimally invasive cardiac surgery is undergoing an explosive evolution, and although the indications and best strategies for the different categories are yet to be determined, the trend cannot be stopped. We try to distinguish between "fashionable" strategies and those that are truly revolutionary and investments in the future.     

Ankle Arthroscopy: Is Preoperative Marking of the Superficial Peroneal Nerve Important?

The aim of this study was to see whether preoperative marking of the superficial peroneal nerve and its branches before anterior ankle arthroscopy reduced the incidence of nerve injury compared with the available evidence reported in the literature. We reviewed 100 consecutive cases of anterior ankle arthroscopy that had been performed between February 2005 and April 2009. The medical records for all of the patients were reviewed for any documented complications related to the arthroscopic procedure. The patients were interviewed by telephone to find out if they had experienced any temporary or long-term neurologic symptoms after the surgery, and any patient with symptoms suggestive of a neurologic complication was thereafter physically examined in the clinic. A total of 96 (96%) of the patients were followed up for a mean of 15.3 (range 1 to 39) months, and the incidence of post-arthroscopy injury to the superficial peroneal nerve or its branches was 1.04% (1 out of 96 cases). Based on our observations, we believe that marking the superficial peroneal nerve and its branches before anterior ankle arthroscopy is an important and effective way to decrease the risk of iatrogenic nerve injury.     

Extraparenchymal Renal Artery Aneurysms: Is Hypertension an Indication for Revascularization Surgery?

We report here the surgical management of extraparenchymal renal artery aneurysms associated with hypertension and the results of this treatment. From January 1978 through December 1999, 19 consecutive patients with 23 extraparenchymal renal artery aneurysms underwent surgery with renal revascularization techniques. Of these 19 patients, 89.5% had systemic hypertension, and 12 of 16 patients had associated renovascular hypertension. Twenty of the aneurysms were patent, one was chronically thrombosed, and one patient presented with acute thrombosis of abdominal aortic and bilateral renal aneurysms; 11 of the 20 patent cases had significant stenosis in the preoperative arteriography. Seventeen aneurysms (74%) were located on the main trunk of the renal artery. Response of hypertension and renal function were examined. Surgical technique patency was evaluated by life-table methods. Our basic surgical indication for extraparenchymal renal artery aneurysms in this series was renovascular hypertension. Nonrenal hypertension alone does not indicate surgery. We consider the saphenous vein to be the graft of choice for renal revascularization.     

Cryopreservation of Parathyroid Tissue after Parathyroid Surgery for Renal Hyperparathyroidism: Does it Really Make Sense?

Background

Metachronous autotransplantation of cryopreserved parathyroid tissue is a technique for treating postoperative hypoparathyroidism after parathyroid surgery for renal hyperparathyroidism (rHPT). The aim of the present study was to evaluate our institution’s experience with metachronous autotransplantation to analyze the role of cryopreservation in the treatment of rHPT and to determine for whom and when cryopreservation of parathyroid tissue should be deemed necessary.

Methods

A prospective database of patients with rHPT who underwent surgery between 1976 and 2011 was screened for patients with hypoparathyroidism who received a metachronous autotransplantation. Data were analyzed regarding clinical data, histopathological findings of the cryopreserved parathyroid tissues, and patient outcome after metachronous replantation of parathyroid tissue.

Results

Fifteen of 883 patients with rHPT underwent a metachronous autotransplantation under local anesthesia at a mean time of 23?months following the last cervical surgery. Histopathology of the parathyroid tissue chosen for transplantation revealed a necrosis rate of 0?% in 14 and 70?% in one patient. Mean preoperative serum calcium and parathyroid hormone (PTH) levels were 2.0?mmol/l and 3.7?pg/ml, respectively. Autotransplantation raised mean serum calcium and PTH levels to 2.2?mmol/l and 97.5?pg/ml, respectively, after a mean follow-up of 78?months.

Conclusions

Metachronous autotransplantation following parathyroid surgery in patients with rHPT effectively normalizes PTH and calcium levels. The success rate is high if an adequate cryopreservation procedure is applied. However, it is rarely necessary, and therefore the cryopreservation of parathyroid tissue in all patients has to be questioned, at least from an economic point of view.     

Impact of Preoperative Risk Factors on Morbidity after Esophagectomy: Is There Room for Improvement?

Background

Despite progress in multidisciplinary treatment of esophageal cancer, oncologic esophagectomy is still the cornerstone of therapeutic strategies. Several scoring systems are used to predict postoperative morbidity, but in most cases they identify nonmodifiable parameters. The aim of this study was to identify potentially modifiable risk factors associated with complications after oncologic esophagectomy.

Methods

All consecutive patients with complete data sets undergoing oncologic esophagectomy in our department during 2001–2011 were included in this study. As potentially modifiable risk factors we assessed nutritional status depicted by body mass index (BMI) and preoperative serum albumin levels, excessive alcohol consumption, and active smoking. Postoperative complications were graded according to a validated 5-grade system. Univariate and multivariate analyses were used to identify preoperative risk factors associated with the occurrence and severity of complications.

Results

Our series included 93 patients. Overall morbidity rate was 81 % (n = 75), with 56 % (n = 52) minor complications and 18 % (n = 17) major complications. Active smoking and excessive alcohol consumption were associated with the occurrence of severe complications, whereas BMI and low preoperative albumin levels were not. The simultaneous presence of two or more of these risk factors significantly increased the risk of postoperative complications.

Conclusions

A combination of malnutrition, active smoking and alcohol consumption were found to have a negative impact on postoperative morbidity rates. Therefore, preoperative smoking and alcohol cessation counseling and monitoring and improving the nutritional status are strongly recommended.     

Is Patient Outcome Affected by the Administration of Intravenous Fluid During Bowel Preparation for Colonic Surgery?

INTRODUCTION

We have previously shown that Picolax® bowel preparation causes a significant dehydrating effect, which can be minimised by administering a calculated volume of intravenous fluid. The aim of this prospective study was to assess whether peri-operative outcome is affected by administering a calculated volume of intravenous fluid during bowel preparation.

PATIENTS AND METHODS

Patients having bowel preparation (Picolax®: Ferring Pharmaceuticals Ltd, Middlesex, UK) prior to colonic surgery were prospectively randomised to receive no intravenous fluid (group 1) or calculated intravenous crystalloid based on their body weight (group 2), during preparation. In both groups, transfusion was protocol-driven. Outcome variables measured included intra-operative and postoperative intravenous fluid requirement, hourly recorded urine output for 24 h, number of patients transfused, number of units of blood transfused, time to the passage of flatus, time to having their bowels open, time until tolerating a full diet, complications and length of stay in hospital.

RESULTS

Thirty-three patients were recruited – group 1 (n = 18) and group 2 (n = 15). There were 24 men and 9 women, median age 69 years (range, 29–86 years). There was no significant difference between the groups with respect to age, sex, weight, ASA grade, preoperative haemoglobin concentration, duration or type of operation. The total number of patients receiving a transfusion (P = 0.026) and the number of units of blood transfused (P = 0.017) was significantly greater in group 1. The number of units of blood transfused intra-operatively was significantly greater in group 1 (P = 0.029). Significantly fewer patients had a urine output <30 ml/h in the first 24-h after operation (P = 0.046) in group 2. There was no difference between groups in other outcomes measures.

CONCLUSIONS

This study indicates that a calculated volume of intravenous fluid administered during bowel preparation improves patient outcomes with respect to blood transfusion and postoperative oliguria. We advocate calculated intravenous fluid administration in all patients undergoing bowel preparation prior to colonic surgery.     

Is Surgery Necessary for Femoral Insufficiency Fractures after Long-term Bisphosphonate Therapy?

Background  

Prolonged use of bisphosphonates in patients with osteoporosis reportedly induces femoral insufficiency fractures. However, the natural course of these fractures and how to treat them remain unknown.     

Is Cardiac Surgery Justified in Patients in the Ninth Decade of Life?

BACKGROUND: Due to aging of the population the upper-age limit for cardiac operations has constantly been extended. In the current era of health care reform the ability to provide appropriate care for geriatric patients at acceptable costs is a major individual and societal concern. The objective of this study was to evaluate the results of cardiac surgery in octogenarians regarding overall morbidity and mortality as well as to quality of life. METHODS: Between February 1992 and August 1995, 101 consecutive octogenarians underwent several types of cardiac operations. Operative procedures consisted of coronary artery bypass grafting (CABG) in 45 patients, valve replacement or repair in 33 patients, and combined CABG and combined procedures in 19 patients. All surviving patients were mailed a questionnaire 3 to 62 months (22.1+/-15.4 months) postoperatively concerning the postoperative course and quality of life (97.5% follow-up). RESULTS: The early mortality was 15.5% in the CABG group, 3.0% in the valve group, and 21.7% in the combined procedure group; 5-year actuarial survival was 79.1% in the CABG group, 86.9% in the valve group, and 58.8% in the combined procedure group, respectively. The questionnaire sent to the survivors revealed that 81.0% of patients considered their functional status better or much better than before surgery. Of the survivors, 97.3% stated that according to their opinion the operation was worthwhile. CONCLUSION: Cardiac surgery is justified for carefully selected patients in the ninth decade of life. Although these patients are at increased risk of operative death and surgical complications compared with younger patients, the majority regain a life expectancy in the range of that of the global population. Furthermore, they are presented the chance to retain or maintain an independent lifestyle.