Current perspectives in endoscopic vessel harvesting for coronary artery bypass grafting

Coronary artery bypass grafting is still the most commonly performed procedure in cardiac surgery. Minimally invasive or endoscopic vessel harvesting was developed a decade ago. It has been shown that these less traumatic techniques significantly reduce wound healing problems and improve patient satisfaction. However, there are some concerns regarding bypass patency and long-term outcomes. The aim of this article is to describe the historic development of endoscopic vessel harvesting, different harvesting techniques and to give an update of the scientific evidence and the current debate regarding outcome and safety of these minimally invasive techniques.     

Advances in the surgical treatment of coronary artery disease

Several new surgical approaches to coronary artery disease revascularization have been developed to avoid the adverse effects associated with conventional coronary bypass graft surgery and the use of cardiopulmonary bypass. This article describes some of these approaches, including minimally invasive direct coronary artery bypass graft surgery, port access surgery, hybrid of integrated coronary revascularization, radial artery and endoscopic vein harvesting, and transmyocardial revascularization. This article also identifies the nursing considerations for each of these surgeries.     

内窥镜下获取大隐静脉在冠状动脉旁路移植术中应用价值

目的比较内窥镜技术与常规开放式获取大隐静脉在冠状动脉旁路移植术围术期的安全性和近期疗效,探讨内窥镜下获取大隐静脉在冠状动脉旁路移植术中的应用价值。方法冠状动脉旁路移植术患者202例,其中采用内窥镜获取大隐静脉者103例为内窥镜组,采用常规开放式获取大隐静脉者99例为对照组,比较2组手术时间、术毕静脉桥总干平均血流量和搏动指数、术中输血比率、术后呼吸机使用时间、围术期病死率、术后并发症发生情况、术后第1、2、3天肌酸激酶同工酶和高敏肌钙蛋白T水平、术后左室射血分数、术后住院时间,观察2组患者术后1周下肢切口愈合情况。结果内窥镜组术后下肢切口麻木、水肿和疼痛发生率(5.8%、6.8%、7.8%)低于对照组(22.2%、20.2%、25.3%)(P<0.05),内窥镜组糖尿病患者术后下肢切口麻木、水肿和疼痛发生率(2.9%、2.9%、5.9%)低于对照组糖尿病患者(25.6%、30.8%、30.8%)(P<0.05);内窥镜组术后第1、2、3天血清高敏肌钙蛋白T[194.90(122.10,314.50)、150.50(88.40,223.30)、115.10(67.00,174.30)ng/L]和肌酸激酶同工酶[5.16(3.45,9.52)、3.56(2.15,5.65)、1.87(1.11,2.78)μg/L]与对照组[164.40(92.00,248.40)、122.80(69.90,224.50)、87.64(36.70,152.50)ng/L,4.96(3.33,9.31)、3.50(2.53,4.63)、1.94(1.21,2.85)μg/L]比较差异无统计学意义(P>0.05),术后第1、2、3天,2组血清高敏肌钙蛋白T和肌酸激酶同工酶水平均依次降低(P<0.05),均高于术前(P<0.05);内窥镜组术毕静脉桥总干平均血流量[(69.41±39.25)mL/min]和搏动指数(1.91±0.71)与对照组[(78.58±35.74)mL/min、1.92±0.67]比较差异无统计学意义(P>0.05);2组手术时间、术中输血比率、术后呼吸机应用时间、术后左室射血分数、术后住院时间及围术期病死率、术后并发症发生率比较差异均无统计学意义(P>0.05)。结论内窥镜下获取大隐静脉在冠状动脉旁路移植术中有良好的围术期效果,与传统获取大隐静脉的方法相比,可减少下肢伤口麻木、疼痛和水肿发生率。     

Ultrasound use in cardiothoracic surgery

With the advent of minimally invasive surgical techniques, patients in the United States currently are undergoing safer, more comfortable surgical procedures than in the past. Traditionally, saphenous vein harvesting techniques involved open surgical techniques that could become sources of postoperative complications, including pain, poor wound healing, increased length of hospital stay, and higher costs for the patient and hospital. These complications were the impetus for developing minimally invasive techniques for vein harvesting. Minimally invasive saphenous vein harvesting is performed through small incisions and subcutaneous tunnels. The procedure offers an atraumatic conduit for the coronary artery bypass procedure and decreases the number of leg wound complications. Ultrasound devices currently offer a quick, accurate method for locating veins before harvest, thereby avoiding wound complications and injuries.     

冠状动脉旁路移植术中联合应用内窥镜采集大隐静脉和直视采集桡动脉与单纯应用内窥镜采集大隐静脉的比较

目的:探讨内窥镜采集大隐静脉联合直视采集桡动脉在冠状动脉旁路移植术中的应用效果。方法:2009年1月至2010年6月,35例冠状动脉旁路移植患者联合应用内窥镜采集大隐静脉(EVH)和直视桡动脉采集(联合组),同期28例患者单纯应用EVH(单纯组)。对比两组患者搭桥支数、切口并发症、采集大隐静脉时间、采集大隐静脉长度,采集移植血管长度,采集移植血管时间。结果:两组患者搭桥支数[联合组(3.56±0.76)支,单纯组(3.48±0.82)支,P=0.78]和切口并发症(联合组17.1%,单纯组14.3%,P=0.61)均无明显差异。联合组采集大隐静脉长度较单纯组显著短[联合组(23.6±3.4)cm,单纯组(42.1±7.2)cm,P<0.001],采集大隐静脉时间显著较单纯组少[联合组(33.2±10.8)min,单纯组(44.3±11.4)min,P<0.001]。联合组采集桡动脉血管长度(17.5±2.6)cm,耗时(36.5±6.7)min。两组采集移植血管长度无明显差异[联合组(43.4±6.1)cm,单纯组(42.1±7.2)cm,P=0.82],采集移植血管时间联合组明显少于单纯组[联合组34.1±8.7)min,单纯组(44.3±11.4)min,P<0.001]。结论:在冠状动脉旁路移植术中联合内窥镜采集大隐静脉和直视采集桡动脉,减少了内窥镜采集大隐静脉的长度,缩短了手术时间,有较好的临床应用价值。     

Minimally invasive saphenous vein harvesting

The intent of this article is to describe the emergence and continuing evolvement and improvement in harvesting saphenous veins by the minimally invasive versus the traditional open technique. The comparison of endoscopic versus open techniques, patient population, systems limitations, clinical outcomes, and perioperative care of the patient will be discussed. The author's intent is to take a multidisciplinary approach.     

AANA journal course: update for nurse anesthetists--anesthetic considerations for minimally invasive direct vision coronary artery bypass grafting.

A recently developed procedure known as MIDCAB (minimally invasive direct vision coronary artery bypass) offers a select group of patients with coronary artery disease an alternative to coronary artery bypass grafting with cardiopulmonary bypass. Compared with customary coronary artery bypass graft surgery, the MIDCAB procedure has a smaller modified incision, requires less operative time, eliminates the risk of cardiopulmonary bypass, and is, as the name implies, far less invasive. Single or multiple vessels are revascularized while the heart remains warm and beating. Movement of the beating heart is dampened in the area of the targeted bypass vessel with the use of mechanical stabilizers by the surgeon. The heart rate may be pharmacologically slowed by the anesthetist. The combination of slowed heart rate and mechanical tamponade by the stabilizers may lead to profound hemodynamic and ischemic changes that may be poorly tolerated in a patient with multiple vessel disease and concurrent disease processes. Extubation and recovery times are far shorter for MIDCAB procedures, leading to earlier discharge and substantial cost savings. The surgical techniques for cardiac bypass surgery have evolved dramatically during the past few years. It is the unique combination of anesthetic monitoring, quick response to hemodynamic changes, and manipulation of physiologic parameters that makes providing anesthesia for minimally invasive cardiac bypass surgery exceptionally challenging.     

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage,hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.     

Video assisted endoscopic saphenous vein harvest

Summary

The saphenous vein remains the mainstay as the conduit in a great majority of coronary artery bypass operations. The traditional method of vein harvesting results in substantial morbidity. An alternate, less traumatic method for saphenous vein harvest is desirable to reduce or eliminate healing problems in the legs. A system of endoscopic vein harvest was utilized to harvest the saphenous vein through one or more small incisions in 81 patients from 14 May 1996 to 12 September 1996. The system consists of subcutaneous tunnelling and dissecting instruments using a video camera for visualization. To date, no major wound complications have been encountered in 114 harvest sites. Minor drainage, haematomas or ecchymoses have not required additional treatment and have not delayed recovery. Patient acceptance has been enthusiastic. We conclude that this technology represents a breakthrough in reducing the annoying and costly morbidity associated with saphenous vein harvest. The initial cost of the equipment and longer operating times initially will be more than offset by a reduction in the need for follow-up treatment and avoidance of delayed recovery.     

内窥镜取大隐静脉在冠状动脉搭桥术中的应用

目的 比较内窥镜与传统手术方法在冠状动脉搭桥术提取大隐静脉中的临床效果.方法 自2007年3月至2008年6月,215例患者接受冠状动脉搭桥手术,87例接受内窥镜手术方法提取大隐静脉,128例接受传统手术方法提取大隐静脉.结果 术后随访1～17个月,内窥镜组在腿部伤口愈合、疼痛、腿部水肿恢复、皮肤感觉方面明显优于传统手术组,差异有统计学意义(P均＜0.05).结论 内窥镜提取大隐静脉手术创伤小,可以显著降低腿部伤口的并发症发生率,提高患者满意度,而且不影响静脉质量,是一种较好的方法.     

内窥镜辅助下国产大隐静脉采集系统在冠脉旁路移植术中的应用

目的:总结内窥镜辅助下国产大隐静脉采集系统采集大隐静脉(endoscopic vein harvestingEVH)在冠脉旁路移植术(CABG)中应用的早期临床效果。方法:自2010年1-12月84例连续进行冠脉旁路移植术的患者中,36例采用EVH,48例采用间断皮肤切口采集大隐静脉。结果:两组所采集的大隐静脉长度差异无统计学意义(P>0.05)。EVH组较间断切口组的大隐静脉采集时间长(P<0.05),但切口总长度(P<0.05),切口缝合时间明显缩短。在术后1个月内,EVH组和间断切口组分别有13.9%(5/36)和37.5%(18/48)发生下肢切口脂肪液化、红肿、感染等并发症。EVH并发症发生率低于间断切口组切口组,差异有统计学意义(P<0.05)。结论:EVH是冠状动脉微创手术的一个组成部分,是安全和值得推荐的可选择的大隐静脉采集方法。     

Minimally invasive heart valve surgery: already established in clinical routine?

Cardiac valve replacement with the need for open heart surgery still has the highest morbidity and mortality rates among routine cardiac surgery, with the exception of aortic aneurysm repair and surgery for congenital heart defects. Reducing invasiveness is a desirable goal, and different strategies and approaches have been used to achieve this with valve repair or replacement less invasive. Despite the good results reported with minimally invasive techniques, time on extracorporal circulation is always longer compared with the conventional procedures. Since these techniques do not reduce real invasiveness but rather improve the cosmetic results, minimal-access surgery would be a better nomenclature. With the exception of patients at a high risk for sternal infections or redo heart operations, a reduction in postoperative morbidity by the avoidance of a median sternotomy is not yet definitely proven. Meanwhile, most surgeons comply with the demand for minimally invasive surgery posed by patients by reducing the length of the incision in aortic valve replacement and by using a right anterolateral approach with a limited incision for mitral valve operations. However, the use of endoscopic or robotic devices is limited to a few centers, and has not yet found its way into clinical routine. Nonetheless, minimally invasive or minimal-access surgery is now established in many centers, and patients should always be informed of these techniques. When this information is provided objectively and patient selection is carried out accurately, these alternative approaches can help to improve postoperative convalescence.     

超声内镜及内镜黏膜下剥离术对直肠类癌的诊疗价值

目的探讨超声内镜(EUS)对直肠类癌治疗的指导价值,及内镜黏膜下剥离术(ESD)对直肠类癌治疗的安全性及有效性。方法对临床考虑直肠类癌的患者进行EUS检查,根据EUS结果选择适合的治疗方案。结果 45例术前病理确诊的类癌病例,42例经ESD治疗,2例累及固有肌层及1例浸透浆膜层并伴有周围淋巴结转移者,经外科手术治疗。结论 EUS能够明确直肠类癌的大小、浸润深度、有无周围淋巴结肿大,对其治疗有较高的指导价值。对于小于20 mm直肠类癌,ESD是一种安全、有效的方法。     

Retracted: Microwave ablation with cooled‐tip electrode for liver cancer: An analysis of 160 cases

Summary

Alongside conservative therapy regimes, an increasing number of surgical procedures is now available for spinal treatment. With the growing number of endoscopic techniques, the spinal surgeon has more procedures from which to choose, Endoscopic techniques are less invasive on the patient and results show a reduced rate of postoperative risks, e.g. post-diskectomy (failed back) syndrome and comorbidity. Endoscopic techniques are used for treatment of a variety of disorders of the cervical, thoracic and lumbar spine, especially spinal disk protrusions. These techniques are also integrated in a number of spinal surgery procedures, such as thoracoscopic, laparoscopic and retroperitoneal procedures, spinal fusion operations, fracture treatment and tumour extraction. Although there is room for technical improvement and the addition of navigation systems has just begun, the preliminary results are very promising and justify the increased technical requirements and extensive training.     

超声内镜在154例上消化道黏膜下肿瘤患者微创治疗中的应用

目的 探讨超声内镜指导下内镜微创治疗上消化道黏膜下肿瘤的应用价值.方法 对内镜发现的154例上消化道黏膜下肿瘤患者根据超声内镜检查结果选择不同内镜微创治疗方案,术后常规行病理学及免疫组化检查,定期内镜随访.结果 154例采用内镜微创治疗,其中皮圈套扎术83例、高频电凝电切37例、内镜黏膜切除术26例、内镜黏膜下剥离术8例.除1例因出血中转手术外,其余均成功切除病灶,无严重出血、穿孔等并发症.超声内镜诊断与术后病理性质符合率为92.8％,来源层次符合率90.6％.113例内镜术后随访1～24个月,未见复发.结论 在超声内镜指导下选择不同方法进行内镜下切除黏膜下肿瘤是一种安全、有效的微创治疗手段.     

Endoscopic repair of groin hernia--what ist evidence-based

The endoscopic techniques of groin hernia repair have developed tremendously over the past 10 years. There are numerous prospective randomized clinical trials comparing conventional techniques of groin hernia repair with endoscopic methods. However, it is difficult to establish a proper meta-analysis of the currently available data due to widely differing study designs. We assessed the currently available prospective randomized clinical trials comparing conventional versus laparoscopic hernia repair. We conclude that based on present data there is a clear advantage for the endoscopic techniques regarding length of hospital stay, postoperative recovery and return to normal activity. The conventional techniques are superior regarding duration of operation and direct cost. Rate of recurrence are comparable in both, endoscopic and conventional approach using mesh prosthesis. Endoscopic techniques are far superior to conventional operation without the use of mesh prosthesis. In patients with recurrent hernia endoscopy offers a major advantage regarding postoperative pain, lenght of hospital stay, return to normal activity and rate of recurrence. We demonstrate these suggestions discussing our own results. Therefore we recomend endoscopic hernia repair in patients with bilateral or recurrent hernia.     

食管平滑肌瘤的内镜微创治疗

[目的]探讨内镜微创套扎手术在食管平滑肌瘤治疗中的临床应用价值.[方法]回顾性分析采用内镜微创套扎手术治疗的21例食管平滑肌瘤患者的临床资料.[结果]胃镜下食管平滑肌瘤套扎术16例,胃镜下黏膜切除术（EMR）3例,2例因为肿瘤瘤体过大转开胸手术,19例手术顺利,术后恢复平稳,无手术死亡及严重并发症,术后病理诊断均为平滑肌瘤.随访2～70个月,无复发.[结论]内镜微创套扎手术可作为食管平滑肌瘤的一种微创治疗方法,对于直径小于0.5 cm的食管平滑肌瘤,可行胃镜下黏膜切除术.     

ENDOSTAB: An Endoscopic Pressure Stabiliser for Minimally-Invasive Cardiac Surgery using Specially Etched Superelastic NiTi Wires for Joint-like Behaviour

For a long time, the only way to access the heart for a bypass operation was to sever the sternum (median sternotomy). Encouraged by the successes achieved by minimally-invasive surgery in other fields, cardiosurgery underwent rapid development, which eventually enabled thoracoscopic operations of the heart. Only with the development of complex robot systems and telesurgery, however, did it become possible to perform exclusively endoscopic bypass operations. Today, the heart-lung machine (HLM) is used as a standard device for bypass operations, with cardiac arrest induced by an infusion. Studies have shown that the HLM may lead to a significant inflammatory reaction and that it is advantageous, particularly for patients with bad cardiac function, to avoid cardiac arrest and keep the heart continuously supplied with blood. ‘Stabilisers’ have been developed to enable bypass operations on the beating heart without using an HLM. For operations on the beating heart using an exclusively endoscopic robot system, an endoscopic stabiliser has been developed, in cooperation with the Leipzig Cardiovascular Institute. The stabilisers that are already available are rigid and, hence, only suitable for an ‘open’ intervention, in conjunction with a retractor. Based on a flexible, superelastic unit made of NiTi, a stabiliser has now been developed that allows endoscopic insertion via a tube of 10 mm in diameter. Joint-like behaviour is achieved by the shaping of the NiTi wires and the specific removal of material in the curved areas. In the operating state, the stabiliser IS still rigid enough to immobilise the desired vascular section. The ENDOSTAB endoscopic stabiliser has already been successfully used in animal experiments at the Leipzig Cardiovascular Institute. The way is thus paved for exclusively endoscopic bypass operations on the beating heart without the use of an HLM.     

十二指肠隆起性病变的内镜治疗

目的分析十二指肠隆起性病变内镜治疗的安全性及有效性。方法对十二指肠隆起性病变患者内镜治疗的临床资料、内镜治疗方法、病理特点、并发症和随访情况进行回顾性分析。结果 112例患者中111例均行内镜治疗,1例中转外科治疗。其中行电凝灼烧术49例,圈套切除术+内镜下黏膜切除术(EMR)36例,内镜黏膜下剥离术(ESD)27例。并发症发生率16.96%(19/112),其中1例因术中大出血,止血困难,中转开腹治疗,7例术中活动性出血,予电热活检钳止血治疗,穿孔6例,迟发性出血2例,一过性淀粉酶升高2例,迟发性穿孔1例。术后随访1~12个月总有效率100.0%。结论内镜治疗十二指肠隆起性病变,具有创伤小、恢复快、费用低和并发症少等优点,内镜治疗将在十二指肠肿瘤中发挥重要的作用。     

内镜黏膜下剥离术与外科手术治疗早期胃癌的有效性及安全性的Meta分析

目的内镜黏膜下剥离术(ESD)与外科手术是早期胃癌(EGC)的常用治疗方法,但其相关风险及获益目前仍存在争议,该研究旨在比较两种治疗方法在治疗EGC的有效性、安全性等方面的差异。方法检索1990年1月-2016年6月发表在Pubmed、CBM、Embase、Cochrane Library、中国知网数据库、维普数据库及万方数据库的有关ESD与外科手术治疗EGC对比研究的所有中英文文献,根据纳入和排除标准对搜索的相关文献进行二次筛选,并对纳入的研究进行质量评价,采用Revman 5.3软件进行Meta分析。结果总共有12篇文献符合纳入标准,且均为回顾性队列研究,共涉及4 331个研究对象。Meta分析的结果显示:ESD与外科手术相比,复发率[(22/2 586,0.85%)vs(6/1 134,0.53%),P=0.370]及5年生存率[(852/909,93.72%)vs(707/746,94.77%),P=0.340]差异无统计学意义,虽然外科手术在整块切除率方面稍高于ESD组[(99/99,100.00%)vs(95/103,92.23%),P=0.020],但是外科手术组的手术时间[标准化均数差(SMD)=-3.04,95%CI:-3.64~-2.45,P=0.000]及住院时间(SMD=-2.53,95%CI:-3.73~-1.32,P=0.000)比ESD组延长,且术后并发症增多[(45/816,5.50%)vs(101/686,14.72%),P=0.000]。结论对于EGC的治疗,两种治疗方法在复发率及5年生存率方面无明显差异,虽然ESD组在整块切除率上不及外科手术组,但其具有创伤小、手术时间短、术中及术后并发症少、住院时间短且恢复快等显著优势,可作为EGC的首选治疗方法。