In elective arch surgery with circulatory arrest,does the arterial cannulation site really matter? A propensity score analysis of right axillary and innominate artery cannulation

Objective

The preferred arterial cannulation site for elective proximal aortic procedures requiring circulatory arrest varies, and different sites have been tried. We evaluated the relationships between arterial cannulation site and adverse outcomes, including stroke, in patients undergoing elective aortic arch surgery.

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. METHODS: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. RESULTS: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). CONCLUSIONS: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.     

Axillary versus femoral cannulation for aortic surgery: enough evidence for a general recommendation?

There is a trend towards cannulation of the axillary artery for extracorporeal circulation in patients requiring aortic arch surgery. We analyzed the published data comparing axillary and femoral cannulation for safety and outcome. End points were death; stroke, neurologic, and vascular complications; and malperfusion. Femoral cannulation is safe for extracorporeal circulation in patients without aortic arch surgery. In patients with type A dissections, malperfusion may occur owing to retrograde perfusion of the false lumen and subsequent occlusion of the origin of the supra aortic vessels. Cannulation of the axillary/subclavian artery results in antegrade flow, at least in the right carotid artery, with the possibility of antegrade cerebral perfusion during aortic arch repair. There was a trend towards improved neurologic outcome when the axillary artery was used for extracorporeal circulation in such patients. When different techniques were compared, the use of a side graft for axillary cannulation reduced the complication rate. The lack of randomized trials and the high variety of inclusion criteria in the different studies do not allow a general recommendation for the use of the axillary artery as cannulation site.     

Does routine use of aortic ultrasonography decrease the stroke rate in coronary artery bypass surgery?

Purpose: The purpose of this study is to determine whether the routine use of intraoperative surface aortic ultrasonography decreases the stroke rate in coronary artery bypass graft surgery (CABG).Methods: One hundred ninety-five consecutive patients undergoing CABG between July 1, 1992, and June 30, 1993 (study group), were evaluated by intraoperative surface aortic ultrasonography. Based on information obtained, changes in the operative technique were made in an effort to decrease the incidence of embolic stroke from unsuspected atherosclerotic disease of the ascending aorta. The outcome of these patients was compared with that of 164 consecutive patients who underwent CABG between July 1, 1991, and June 30, 1992 (control group), in whom the ascending aorta was assessed by inspection and palpation only.Results: Significant disease was detected in three (2.0%) of 164 patients in the control group. Modifications in their operative technique consisted of hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in two patients and single cross-clamping in one patient. There were five strokes overall in this group (3.0%), and six patients died (3.6%), one in whom the stroke contributed directly to the cause of death. In the study group the ultrasonic findings were normal to mild in 168 patients, moderate in 20 patients, and severe in seven patients. These results led to a modification of the technique in 19 patients, (10%): hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in 14 patients, modification in the aortic cannulation site or single cross-clamping in three patients, and modification in placement of proximal anastomoses or all arterial grafts in two patients. No strokes occurred in this group ( p < 0.02, Fisher's exact test). Five patients died, for an operative mortality rate of 2.6%.Conclusion: These data indicate that intraoperative ultrasonography of the ascending aorta with simple modifications in operative technique reduces the stroke rate in CABG. (J V ASC S URG 1995;21:98-109.)     

Is aortic surgery using hypothermic circulatory arrest in octogenarians justifiable?

OBJECTIVE: This study was undertaken to analyze the risk of mortality and neurological complications after aortic surgery requiring hypothermic circulatory arrest (HCA) in octogenarians. METHODS: All patients of >80 years at the time of aortic surgery requiring HCA since 1988 were examined. Of 51 patients, 23 were male; the median age was 83. Twenty-six (51%) had proximal repair; the arch was replaced in eight (16%), and 17 (33%) had descending aorta repair. Eleven (22%) were emergencies. Multivariate analysis was carried out to determine the risk factors for in-hospital mortality and/or stroke (adverse outcome) using variables with P<0.1 after univariate analysis. RESULTS: The hospital mortality was 16%. Five patients suffered strokes (9.8%): only one survived >6 months, and three died before discharge. The overall adverse outcome was 22%, but elective operation was associated with much better results, with an adverse outcome of only 3.6% after operations via a median sternotomy. Adverse outcome was strikingly higher with more distal resections via a left thoracotomy: 47 vs. 8.8% for ascending aorta/arch resections (P=0.003). Emergency operation via a lateral thoracotomy was associated with a prohibitively high adverse outcome. Twenty-nine patients (73%) had temporary neurological dysfunction (TND). Multivariate analysis revealed emergency operation (P=0.01; odds ratio (OR), 10.6) and operations via a lateral thoracotomy (P=0.008; OR, 11) as independent preoperative predictors of adverse outcome. The overall survival was 66% at 2 years and 39% at 5 years, compared with 85 and 52% among age- and sex-matched controls. CONCLUSIONS: Aortic surgery utilizing HCA in octogenarians can be performed with an acceptable risk of mortality and stroke. From the evidence in this study, it seems that elective aneurysm repair via a median sternotomy can be undertaken for the usual indications, even in octogenarians. However, the enhanced vulnerability of the brain in the elderly is reflected by a high early mortality following stroke, and a high incidence of TND. Emergency operations increase the possibility of adverse outcome dramatically, and patients who require a lateral thoracotomy are at significantly higher risk than those operated via a median sternotomy.     

Is ambulatory surgery suitable for cancer patients?

The aim of this inquiry was to question 50 patients before a traditional hospitalization in a regional center, in order to know their opinion about one-day surgery. Among 44 answers from 41 women and 3 men, 29 were against, 11 favourable and 4 without opinion. After their hospitalization, only 4 changed their mind. The main reasons, in case of unfavourable answer, were lack of security and fear of pain. Psychologic aid in traditional hospitalization is frequently cited (34%). This has to be taken into account in ambulatory cases.     

Is adenosine preconditioning truly cardioprotective in coronary artery bypass surgery?

BACKGROUND: The large number of experimental studies showing that adenosine "turns on" the protein kinase C (PKC)-mediated pathway that accounts for the cardioprotection conferred by ischemic preconditioning contrasts with the scarcity of clinical data documenting the preconditioning-like protective effect of adenosine during cardiac operations on humans. METHODS: Forty-five patients undergoing coronary artery bypass were randomized to receive, after the onset of cardiopulmonary bypass, a 5-minute infusion of adenosine (140 microg x kg(-1) x min(-1)) followed by 10 minutes of washout before cardioplegic arrest (n = 23) or an equivalent period (15 minutes) of prearrest drug-free bypass (controls, n = 22). Outcome measurements included troponin I release over the first 48 postoperative hours and activity of ecto-5'-nucleotidase, an admitted reporter of PKC activation, as assessed on right atrial biopsies taken before bypass and at the end of the preconditioning protocol (or after 15 minutes of bypass in control patients). RESULTS: Aortic cross-clamping times were not different between the two groups. Likewise, prebypass values of ecto-5'-nucleotidase (nanomoles/mg protein per minute) were similar in control (3.14+/-1.02) and adenosine-treated (2.66+/-1.08) patients. They subsequently remained unchanged in control patients (3.87+/-1.65) whereas they significantly increased after adenosine preconditioning (4.47+/-1.96, p<0.001 versus base line values). However, peak postoperative values of troponin I (microg/L) were not significantly different between control (4.8+/-2.8) and adenosine-preconditioned patients (5.9+/-6.6) nor were the areas under the curve. There were no adverse effects related to adenosine. CONCLUSIONS: Adenosine, given at a clinically safe dose, can turn on the PKC-mediated signaling pathway involved in preconditioning but this biochemical event does not translate into reduced cell necrosis after coronary artery surgery, suggesting that a preconditioning-like protocol may not be the best suited for exploiting the otherwise well-documented cardioprotective effetcs of adenosine.     

Is a completion axillary dissection indicated for micrometastases in the sentinel lymph node?

OBJECTIVE: The purpose of this study is to determine if a completion axillary dissection (CAD) is necessary when microscopic metastasis (<2 mm) is detected in the sentinel lymph node (SLN) of patients diagnosed with breast cancer. METHODS: A retrospective chart review was performed on 227 consecutive breast cancer patients who underwent SLN mapping (SLNM) between June 1998 and March 2001. These patients underwent intraoperative lymphatic mapping with peritumoral injections of blue dye alone or in combination with technetium-labeled sulfur colloid. The SLN was assessed by touch preparation or frozen section at the time of surgery, and later, by hematoxylin and eosin stain. Patients in whom the SLN showed evidence of metastatic disease on frozen section underwent immediate CAD. RESULTS: One patient was excluded because of inability to identify the SLN. Of the 226 patients in whom SLNM was successful, 67 (27%) had macrometastasis in the SLN, and a completion CAD was performed. Thirty-four of these 67 patients (51%) had additional disease in the axilla. A total of 15 patients (6.7%) was determined to have micrometastasis. In 11 patients, micrometastasis was identified and CAD was performed with no further evidence of disease. The 4 patients diagnosed with micrometastatic disease on permanent staining did not have further surgical intervention. The 15 patients identified with micrometastasis show no evidence of local recurrence to date, with a mean follow-up of 13.5 months (range 1 to 27). CONCLUSIONS: This study suggests that CAD may not be necessary for the subset of breast cancer patients with micrometastasis detected upon SLNM. A larger randomized prospective study with long-term follow up is necessary to confirm these data.     

Is there a role for surgery in the treatment of mastalgia?

Breast pain is a common condition affecting most women at some stage in their reproductive life. Mastalgia is resistant to treatment in 6% of cyclical and 26% non-cyclical patients. Surgery is not widely used to treat this condition and only considered in patients with severe mastalgia resistant to medication. The aims of this study were to audit the efficacy of surgery in severe treatment resistant mastalgia and to assess patient satisfaction following surgery. This is a retrospective review of the medical records of all patients seen in mastalgia clinic in the University Hospital of Wales, Cardiff since 1973. A postal questionnaire was distributed to all patients who had undergone surgery. Results showed that of the 1054 patients seen in mastalgia clinic, 12 (1.2%) had undergone surgery. Surgery included 8 subcutaneous mastectomies with implants (3 bilateral, 5 unilateral), 1 bilateral simple mastectomy and 3 quadrantectomies (1 having a further simple mastectomy). The median duration of symptoms was 6.5 years (range 2-16 years). Five patients (50%) were pain free following surgery, 3 developed capsular contractures and 2 wound infections with dehiscence. Pain persisted in both patients undergoing quadrantectomy. We conclude that surgery for mastalgia should only be considered in a minority of patients. Patients should be informed of possible complications inherent of reconstructive surgery and warned that in 50% cases their pain will not be improved.     

Is the red-yellow-black scheme suitable to classify donor site wounds? An inter-observer analysis

Background

The red-yellow-black-scheme (RYB) is a well-known and validated scheme to classify chronic and acute wounds, based on wound color and moistness. We investigated whether this RYB-scheme is also useful to classify donor site wounds uniformly (DSW).

Methods

Twenty-three digital photographs of DSWs in various stages of wound healing were presented to internationally renowned wound scientists (n = 11), surgical doctors (n = 31), specialized wound nurses (n = 55), and surgical nurses (n = 28). These observers classified the color and moistness of the wound according to the RYB-scheme, yielding seven wound categories. Inter-observer agreement (IOA) was expressed as a kappa (κ) value.

Results

IOA's among specialized wound nurses were moderate when based on wound color and moistness (κ = 0.41; 95% CI 0.33-0.49), wound color only (κ = 0.41; 95% CI 0.29-0.53), or moistness only (κ = 0.54; 95% CI 0.45-0.64). However, these IOA's tended to be better than those among the scientists, doctors and nurses. Scientists showed the lowest agreement (k-values between 0.17 and 0.25). Doctors scored slightly better than nurses.

Conclusion

Clinicians and scientists have difficulty with classifying DSWs by means of the RYB-scheme. Therefore, this scheme does not appear useful to classify donor site wounds in a uniform manner.     

Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PurposeIn elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.MethodsWe conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.ResultsAmong the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).Conclusionspreoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.