Off pump BD Glenn: BIS correlation

Background Bidirectional Glenn procedure can be performed without cardiopulmonary bypass (CPB) with some advantages. But the effect of high central venous pressure can be detrimental on the brain. This short study was undertaken to see the effect of off pump Glenn on Bispectral index (BIS), a sensitive neuro monitor. Method The mean increase in superior vena cava (SVC) pressure, fall in BIS values and postoperative neurological outcomes were observed in five children operated for this procedure. Result The mean age of the patients was 3.09±1.4 years and the mean weight was 10.9±4.6Kg. The mean pre procedure SVC pressure was 5±3 mmHg. The maximum increase in SVC pressure was 38 ± 8.2mmHg from baseline. The mean SVC clamptime was 6.8±2.4 min and the fall in BIS from baseline was 20± 10.2. The lowest BIS recorded was 18. There were no neurological problems. Conclusion In conclusion, BIS is an important adjunct to neuromonitoring in off pump Glenn and should be maintained as near to the normal anaesthetic values of 40–60 as possible by various neuroprotective strategies like maintaining a transcranial gradient, hypothermia and neuroprotective drugs.     

小儿双向Glenn手术的麻醉体会

目的总结复杂性先天心患儿在非体外循环下行双向Glenn术的麻醉管理。方法16例患儿在非体外循环下行双向Glenn术。所有患儿采用静吸复合麻醉方法。麻醉维持主要采用中小剂量的舒芬太尼或芬太尼。并辅以低浓度的七氟醚吸人。结果术毕SpO2、CVP较术前显著升高（P〈0．01）,而术毕Hb及Hct较术前显著降低（P〈0．05）。术后早期均有不同程度的眼睑、面部水肿症状,6例出现全身抽搐等脑缺氧表现,1例术后出现痴呆。除了两例术后早期患儿因低心排血量综合征合并肾功能衰竭而死亡外,患儿术后紫绀症状明显改善。无麻醉并发症。结论在恰当的麻醉方式下,维护心血管功能稳定．维持较高水平的腔静脉压力并降低肺血管阻力以促进肺血流的改善,调控内环境平衡并加强脑保护等是麻醉管理的关键。     

Combined left lower lobectomy and off pump coronary artery bypass grafting through left posterolateral thoracotomy

Carcinoma lung coexists with coronary artery disease in a significant number of patients. If a lung resection can be combined with off pump coronary Artery Bypass grafting in such patients, morbidity and mortality associated with staged procedures can be significantly reduced. Once such case is highlighted here.     

Off Pump coronary artery revascularization via left thoracotomy —Early results

Background There are very few studies in literature, which have reported primary revascularization of the coronaries via a thoracotomy incision. We hereby present our initial experiences using this approach to off pump coronary revascularization. Patients and Methods 27 patients with coronary artery disease were selected for surgical revascularization via the thoracotomy approach. The left chest is entered through the 5^th intercostal space, and the left internal mammary artery (LIMA) pedicle is harvested under direct vision. The radial artery or saphenous vein is harvested simultaneously depending on the availability and suitability of the conduits. Using standard off pump techniques, the LIMA is anastomosed to the Left Anterior Descending Artery (LAD) followed by other distal anastomoses. Results Complete revascularization was achieved in all patients. The average number of grafts were 2.40. The mean blood loss during the first 6 hours was 380 ± 169 ml. None of the patients needed emergency conversion to cardiopulmonary bypass / sternotomy. Post operatively 4 patients had on table extubation. 1 patient was re-explored due to bleeding from the thoracotomy. There was no peri-operative Myocardial infarction and the mortality was nil. The average hospital stay was 6.4 ± 1 days. Conclusion Based on our initial experience, this approach appears to be safe and practical in selected cases. It is well tolerated hemodynamically, with minimal postoperative morbidity.     

经左胸肋间切口实施冠状动脉旁路移植术

目的探讨经左胸肋间切口实施冠状动脉旁路移植术的临床应用与特点。方法我院1996年9月~2005年8月共实施经左胸肋间切口的冠状动脉旁路移植术36例,左侧胸骨旁第4肋间前外侧切口6~10 cm进入胸膜腔,使用M IDCAB专用牵开器,分离左侧乳内动脉与冠状动脉吻合。主要有4种情况:①单纯前降支系统病变;②再次冠状动脉旁路移植术而存在通畅的左乳内动脉至前降支桥;③严重的升主动脉钙化;④合并其他左胸手术。单支病变26例,双支病变3例,三支病变7例。既往介入治疗史5例,冠状动脉旁路移植术史6例。左心室射血分数为(0.562±0.107)。结果36例均成功实施非体外循环心脏跳动下的冠状动脉旁路移植术,远端吻合口1~4个,手术时间(190.4±44.1)m in。合并激光心肌打孔术2例,合并肺癌切除术1例,食管癌切除术1例。无住院死亡病例。32例随访1个月~9年,中位数32月,2例远期死亡。2例术后1年再发心绞痛,1例经介入治疗,另1例再次手术,症状消失。其余患者均没有心绞痛症状。结论经左胸肋间切口实施冠状动脉旁路移植术对某些特殊类型的冠心病患者是安全实用的选择,非体外循环方式下进行此类手术是可行的。     

双向Glenn手术治疗儿童功能性单心室68例分析

目的总结1998年4月至2005年12月行双向Glenn手术治疗68例儿童功能性单心室的经验。方法本组男47例,女21例;年龄5个月～14岁（中位年龄3．7岁）;体重6．7～30．0kg（中位体重12．5kg）。右侧双向Glenn手术39例,左侧双向Glenn手术13例,双侧者16例。同期行肺动脉环束3例、肺动脉结扎1例、主动脉-肺动脉分流管道切断缝合术1例、动脉导管结扎6例、大侧支循环切断4例、全肺静脉异位引流矫治1例、部分肺静脉异位引流矫治2例、房室瓣整形4例。结果68例患者死亡3例,病死率4．4％。术后上腔静脉压力（15．9±2．4）mmHg（1mmHg=0．133kPa）,较术前的（8．3±1．8）mmHg显著上升（P〈0．01）。术后安静时经皮血氧饱和度（89．3±4．2）％,较术前的（78．4±6．0）％显著上升（P〈0．01）。结论双向Glenn手术治疗功能性单心室效果满意;双向Glenn手术宜保留肺动脉的搏动性血流。     

A novel technique for off pump bidirectional Glenn shunt--safety issues--a case report

A new technique to decompress the superior vena cava (SVC) during off pump bi-directional Glenn [BDG] shunts is described. Cerebral protection maneuvers and the safety concerns of the technique are addressed.     

Comparison of on pump and off pump coronary surgery: risk factors for neurological outcome

Objective: Cerebrovascular accidents (CVA) are devastating complications after coronary artery bypass grafting (CABG). The reported incidence of neurological complications after conventional CABG (CCABG) is 3–6%. Off-pump coronary bypass grafting (OPCAB) has been associated in recent studies to a decreased morbidity and risk of perioperative stroke. Nevertheless, uncertainty still surrounds the relative benefits of OPCAB. We investigated whether, in our experience, OPCAB was associated with lower neurological morbidity than conventional CABG approach. Methods: Eight thousand and two patients underwent isolated CABG at our institution between January 1998 and January 2005. OPCAB operation was performed on 1415 patients. Data were prospectively collected. A multiple logistic regression analysis was used to evaluate the influence of the two different surgical techniques on the neurological outcomes. Results: Patients in the OPCAB group were significantly older (66.2 vs 63.5%, p < 0.0001), had a higher incidence of renal injury (5.4 vs 2.4%, p < 0.0001), and were more redo interventions (6.95 vs 1.53%, p < 0.0001). The CCABG patients were more urgent at operation (5.46 vs 3.26, p = 0.0007), were less hypertensive (57.6 vs 63% of the patients, p = 0.0003) more diabetics (22 vs 20.6%, NS), and had an ejection fraction less than 0.40 (10.4 vs 9.6%, NS). CVA incidence was similar in both groups (Type I outcome: OPCAB = 0.70% vs CCABG = 0.68%, p = 0.91; Type II outcome OPCAB = 0.70% vs CCABG = 0.83%, p = 0.63). Conclusions: In our experience patients undergoing CCABG were not exposed to a grater risk of neurological adverse events when compared to OPCAB patients.     

Management of cerebrospinal fluid leakage complicating anterior procedures through thoracotomy: report of three cases

Postoperative cerebrospinal fluid (CSF) leakage is a serious complication accompanying an anterior procedure through thoracotomy, and it is difficult to cure. In this report, we present three patients with CSF leakage in the thoracic spine complicating anterior decompression and fusion for ossification of posterior longitudinal ligament who were treated by surgical or nonsurgical methods. As a surgical method, direct closure by fixing substitute dura mater with fibrin adhesive sealant or cyanoacrylate adhesive was performed in two patients. This technique was effective but required another thoracotomy. As a nonsurgical method, intrapleural administration of OK-432 through chest drainage tubes was also effective to reduce intrapleural effusions in one patient, but with this method, care must be taken for neurotoxic reactions. Both techniques seem to be useful and effective for postoperative intrapleural CSF leakages complicating anterior procedures through thoracotomy. Electronic Publication     

Elective preoperative use of intra aortic balloon counterpulsation in high risk group of coronary artery disease patients to facilitate off pump surgery

Background To avoid the deleterious effects of cardio-pulmonary bypass, off pump coronary artery bypass graft surgery (OPCABG) is increasingly the procedure of choice in the majority of patients needing myocardial revascularization. However patients at high operative risk are sometimes not given the advantage of off pump surgery because of haemodynamic deterioration during displacement of the heart to access the target vessels, or deterioration per se due to the factor causing the high risk (eg unstable hemodynamics) leading to institution of cardio-pulmonary bypass (CPB). Preoperative intraaortic balloon counterpulsation (IABC) therapy improves cardiac performance and facilitates the access to the anastomotic site during off pump coronary artery bypass grafting while maintaining haemodynamic stability. Methods Two hundred and twelve patients for isolated coronary artery bypass grafting (CABG) between June 2000 and June 2006 were studied in whom preoperative IABC was instituted. Initially, the trial was started in two groups and patients were computer randomized to ‘IABC’ and ‘No IABC’ groups. The trial was abandoned after 15 cases in each group, because of the adverse outcomes in ‘No IABC’ group. Left main stenosis was present in 31.1%, triple vessel disease in 87.7%, recent myocardial infarction in 21.2%, 35.8% were hypertensive, and 32% were diabetic. Results Out of 212 cases in whom preoperative IABC was instituted OPCABG was possible in the majority (88.2%), while of 15 cases in ‘No IABP’ group all CABG were done on CPB. Mortality and average stay in ICU was markedly lower in patients where IABC was instituted preoperatively. Conclusions Elective preoperative IABC in patients with high-risk coronary artery disease permits OPCABG in the majority, reduces the ICU stay, leads to earlier weaning from intra aortic balloon pump (IABP), reduces the morbidity and mortality, and is more economical.     

Metabolic changes and clinical outcomes in patients undergoing on and off pump coronary artery bypass surgery

Objective Though the advent of cardiopulmonary bypass saw a dramatic increase in the number of coronary bypass surgeries performed annually, a few surgeons continued to use off pump technique mainly for economic reasons. But the adverse effects of cardiopulmonary bypass necessitated a relook at the off pump technique. The study aims to assess the metabolic changes and clinical outcomes in patients undergoing on or off pump coronary bypass surgery. Methods One hundred patients with severe left ventricular dysfunction undergoing coronary bypass surgery on or off pump, fifty in each group, were studied for the metabolic changes and clinical outcomes. The results were statistically analysed using student’s t test. Results The off pump group showed better postoperative renal function, and less incidence of lactic acidosis and oxidative stress than the cardiopulmonary bypass group. The former also had lesser need for ventilator support, shorter intensive care and hospital stay. Conclusions The off pump technique is associated with reduced myocardial injury, inflammatory response, and postoperative morbidity. This study was supported by a financial grant from Rameshwardas Birla Smarak Kosh, and Dr. P.K. Sen Research Society, Mumbai.     

Repair of esophageal atresia with tracheoesophageal fistula via thoracotomy: a contemporary series

Background

A recent series detailing thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) reported lower complication rates compared with historic controls. This study provides a contemporary cohort of patients repaired via thoracotomy for comparison with the recent large multi-institutional thoracoscopic series.

Methods

Records of patients with EA/TEF between 1993 and 2008 were reviewed. Attention was focused on demographics and complications including anastomotic leak, recurrent fistulae, stricture formation, and need for fundoplication.

Results

Seventy-two patients underwent repair of EA/TEF via thoracotomy. Complication rates in the current series compared with the thoracoscopic series were anastomotic leak, 2.7% versus 7.6%; recurrent fistulae, 2.7% versus 1.9%; stricture, 5.5% versus 3.8%; and need for fundoplication, 12% versus 24%. Differences in complication rates did not reach statistical significance. Two children in this cohort developed mild scoliosis attributed to congenital vertebral anomalies, neither of whom required intervention.

Conclusions

Thoracoscopic repair of EA/TEF yielded complication rates similar to this contemporary series; however, trends toward increased anastomotic leaks and greater need for fundoplication were noted. No musculoskeletal sequelae were directly attributable to thoracotomy.     

Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study

Objective: Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain. Methods: In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 ml kg⁻¹ bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 ml kg⁻¹ h⁻¹ for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1 mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product. Results: Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and saline in terms of pain severity at rest and on coughing, mean postoperative morphine consumption (45.7 mg for ropivacaine, 43.2 mg in controls), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation). Conclusions: Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.     

Right postero-lateral thoracotomy for atrial septal defect closure; a comparative analysis with median sternotomy

Introduction In a low risk procedure like ASD closure Right Posterolateral thoracotomy approach aims at the cosmetic results as compared to median sternotomy. This paper illustrates our approach for a standardised Right Posterolateral thoracotomy in ostium secundum ASD repair and the analysis of the outcome. Methods Right Posterolateral thoracotomy (RPLT) was offered as a cosmetic alternative for atrial septal defect (ASD) closure in children, and selected adult patients below 30 years with lean body build. A retrospective study comparing these patients with median sternotomy approach during the same period (2000–2003) was performed. Exclusion criteria included preoperative diagnosis of complex ASD, obesity and chest wall deformity. Common variables were considered for analysis. Results There were 96 patients (66 females and 30 males) with an average age of 13yrs (range 3 to 27 years) in RPLT group and 225 patients (95 females and 130 males) with average age of 36 years (range 2 to 46 years) in sternotomy group. Extra corporeal time was 32 minutes (28 to 45) and aortic cross clamp time was 14 minutes (8 to 36) in RPLT while the values were 46 minutes (37 to 90) and 22 minutes (18 to 36) in Median sternotomy approach. Blood loss in postoperative period was 160 ml (20 ml to 400 ml) in thoracotomy group compared to 210 ml (40ml to 600 ml) in sternotomy group. There was no mortality or recurrence after repair of ASD during the follow-up. Significant postoperative morbidity was persisting pain and shoulder movement restriction in 12 patients. The scar was cosmetic in RPLT. Conclusion In selected patients with lean body build Right posterolateral thoracotomy is suitable for ostium secundum atrial septal defect closure. The final appearance has definite cosmetic advantage over sternotomy. Presented at the 50^th Annual Meeting of IACTS, New Delhi, Feb., 2004.     

双向Glenn手术治疗紫绀型复杂先天性心脏病

目的总结双向Glenn手术治疗紫绀型复杂先天性心脏病的临床经验。方法回顾性分析2007年1月至2012年12月新疆维吾尔自治区人民医院68例紫绀型复杂先天性心脏病行双向Glenn手术患者的临床资料,其中男40例、女28例,年龄3个月至22岁,平均年龄3.9岁;体重6.2~53.0（13.6±8.5）kg。术前诊断包括三尖瓣闭锁20例,单心室11例,右心室双出口10例,完全型大动脉转位7例,三尖瓣狭窄5例,肺动脉闭锁5例,矫正型大动脉转位4例,法洛四联症4例,三尖瓣下移畸形2例。其中合并右位心、右旋心14例,单心室并肺动脉高压行肺动脉环缩术后2例,完全型大动脉转位行中心分流术后1例。23例和45例紫绀型复杂先天性心脏病分别在体外循环和非体外循环下施行手术。结果术后早期死亡2例,1例死于严重的低心排血量综合征,1例死于肺部感染。脉搏血氧饱和度从术前的66.8%±11.8%提高至出院时的89.3%±7.4%（P〈0.05）。其中53例脉搏血氧饱和度术后较术前升高〉10%。红细胞压积由术前0.49±0.11降至术后的0.40±0.07（P〈0.05）。术后发生胸腔积液16例（23.5%）,乳糜胸7例（10.3%）,低心排血量综合征5例（7.4%）,心律失常4例（5.9%）,气胸1例（1.5%）。以上并发症均经相应的治疗治愈。随访55例,随访时间9个月至6年,所有吻合口血流通畅,无狭窄,无血栓形成,临床效果满意。4例患者分别于术后2~5年完成全腔静脉-肺动脉连接术,恢复顺利。结论双向Glenn手术安全、可靠,是一种治疗难以解剖根治或需一期生理矫治的紫绀型复杂先天性心脏病患者的较好手术术式。     

胸腹腔镜与传统开胸手术治疗老年食管癌的疗效比较

目的比较胸腹腔镜与传统开胸手术治疗老年食管癌的临床疗效。方法将120例老年食管癌患者按照随机、自愿的原则分为对照组和观察组,各60例。对照组实行传统开胸手术,观察组采用胸腹腔镜手术。比较两组手术时间、术中出血量、淋巴结清扫量、术后胸腔引流时间以及术后并发症情况。结果观察组手术时间(326.4±58.3 min)明显长于对照组(299.8±45.2 min),P0.05。观察组术中出血量(362.3±44.7 mL、)和术后引流时间(7.6±1.6 d)明显小于对照组(415.1±72.6mL、9.4±2.4 d),P0.05。两组的淋巴结的清扫量(23.2±6.6个、21.6±6.4个)比较,P0.05,差异无统计学意义。观察组术后并发症(15.0%)明显少于对照组(26.6%),P0.05,差异有统计学意义。结论胸腹腔镜手术治疗老年食管癌患者对机体损伤较小,治疗效果优于传统的开胸手术。     

Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy

Objective: Video-assisted thoracoscopic surgery (VATS) lobectomy has been employed for the treatment of lung cancer. Many investigators have reported that the outcomes of VATS lobectomy for lung cancer are comparable to those of thoracotomy; however, several controversial issues remain. One of the critical concerns is the safety. VATS lobectomy often requires an emergency conversion to thoracotomy, for example, in the event of massive bleeding. In this study, cases in which VATS lobectomy for lung cancer was converted to thoracotomy intra-operatively (converted VATS lobectomy) were identified. The safety of the converted VATS lobectomy was evaluated. Methods: Between 2003 and 2007, VATS lobectomy was converted to thoracotomy in 24 out of 492 cases. Information regarding the patients’ characteristics, reasons for the conversion and perioperative complications as well as the recurrence and survival data were carefully reviewed. The reasons for the conversion were classified into two groups: (1) problems related to the VATS procedure (VATS-related problems) and (2) problems not related to the VATS procedure (non-VATS-related problems). Results: Of the 24 converted cases, 19 (79%) had a history of smoking. Nine patients (38%) had a history of lung disease. Left upper lobectomy was the most frequently associated with conversion (11/24, 46%), followed by right lower lobectomy and right upper lobectomy. The most frequent reasons for the conversion were hilar lymphadenopathy and bleeding (seven patients each), followed by fused fissure. Eight of the conversions were considered to be attributable to VATS-related problems. Perioperative complications were observed in four patients, consisting of prolonged air leak in three patients and transient recurrent laryngeal nerve palsy in one patient. However, there were no life-threatening complications. The median follow-up period was 26 months. Recurrence occurred in two patients: pleural dissemination in one and bone metastasis in the other. Two deaths were observed during the follow-up period: one related to lung cancer and another related to other type of cancer. Conclusions: The safety of the conversion was acceptable. Our findings suggest that VATS lobectomy for lung cancer is feasible from the viewpoint of safety, even after taking into account the potential need for conversion to thoracotomy in some patients.