Off-pump coronary surgery through mini-incisions: is it reasonable?

PURPOSE OF REVIEW: Coronary artery bypass grafting as currently performed is considered the gold standard of coronary revascularization. It also, however, is a potential source of complications, especially in patients with multiple co-morbid risk factors. To alleviate some of these downsides, cardiac surgeons designed minimally invasive procedures performed off-pump, without sternotomy, and through small incisions. The efficacy of these techniques is emerging in the literature. Our aim is to describe the new technique that we are using, and provide an objective review of the recent literature with regards to safety and related surgical outcomes. RECENT FINDINGS: Although no long-term follow-up data exist yet with respect to the specific technique described herein, current evidence suggests that both on-pump and off-pump coronary bypass grafting techniques, when done in experienced centers, provide similar rates of completeness of revascularization, long-term patency, and freedom from surgical reintervention. When applied to patients at high surgical risk, observational studies suggest a decrease in the incidence of stroke, bleeding, renal complications, and mortality with off-pump bypass grafting. SUMMARY: Cardiac surgery performed off-pump without sternotomy is a procedural extension of off-pump bypass grafting which has the potential to be as safe as conventional coronary bypass grafting. The technique could offer an advantage to the high-risk patient population, or to patients for whom return to physically demanding work must be expedient after surgery.     

Is there a role for the left ventricle apical-aortic conduit for acquired aortic stenosis?

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in patients with a heavily calcified ascending aorta and aortic root, or with conditions that preclude a median sternotomy, poses a formidable challenge. A left ventricle apical-aortic conduit (AAC) is an alternative in these situations. Herein, the authors' experience with AAC in adult patients with acquired aortic stenosis is reported. METHODS: Between 1995 and 2003, 13 patients (mean age 71 years) underwent AAC for severe symptomatic aortic stenosis (mean valve area 0.65 +/- 0.02 cm2). Indications for AAC were heavily calcified ascending aorta and aortic root (n = 5), patent retrosternal mammary grafts (n = 4), calcified ascending aorta and aortic root plus patent retrosternal mammary graft (n = 1), retrosternal colonic interposition (n = 1) and multiple previous sternotomies (n = 2). Seven patients had previous coronary artery bypass grafting (CABG). The mean preoperative left ventricular ejection fraction was 50 +/- 4%. RESULTS: AAC were performed under cardiopulmonary bypass through a left thoracotomy (n = 10), median sternotomy (n = 2) or bilateral thoracotomy (n = 1). Hearts were kept beating (n = 5) or fibrillated (n = 7). Circulatory arrest was used in one patient. Composite Dacron conduits with biological (n = 6), mechanical (n = 4) or homograft (n = 2) valves were used. Distal anastomoses were performed in the descending thoracic aorta (n = 12) or in the left iliac artery (n = 1). Two patients underwent simultaneous CABG. Three patients died in-hospital from ventricular failure (n = 1), intravascular thrombosis (n = 1) and multi-organ failure (n = 1). The mean hospital stay was 26 days. Complications included respiratory failure requiring tracheostomy (n = 2), stroke (n = 1) and re-exploration for bleeding (n = 2). At a mean follow up of 2.1 years, there have been four late deaths; causes of death were congestive heart failure (n = 2), ischemic cardiomyopathy (n = 1) and cancer (n = 1). CONCLUSION: AAC provides an acceptable alternative to AVR in selected patients who are at exceedingly high risk for the standard procedure.     

Does the psychological request of the patient justify the surgery for hepatic hemangioma?

BACKGROUND/AIMS: The incidental finding of hemangiomas has increased, but the problem of the correct surgical indications of this tumor has yet to be solved. The aim of this work is to establish whether the psychological request of surgery from patients known to have a benign tumor of the liver must be avoided or not. METHODOLOGY: Age, sex, symptoms, estroprogestinic oral therapy, methods of diagnosis, surgical procedures, morbidity, mortality, postoperative hospital stay and follow-up of the patients affected by hepatic hemangioma, observed from 1992 to 2002 in our institution, have been considered. RESULTS: Seventeen patients, with a mean age of 44 years (range 26-72), were hospitalized for hepatic hemangioma, 8 (47%) of them were operated on and 9 (53%) were managed by observation. The operated patients presented various symptoms. One patient was operated on for traumatic rupture of the hemangioma. Non-operated patients were asymptomatic or with slight dyspeptic symptoms not related with the tumor. The first diagnostic radiological examination was ultrasonography (US) in all cases. All lesions were larger than 4cm. The types of surgical procedures were 5 enucleations, and 3 hepatic resections. All operated patients resolved their clinical symptomatology, except two patients that had requested surgery for psychological implications. These patients presented their symptoms again after 2and 3 years of follow-up respectively. CONCLUSIONS: Our results suggest that liver hemangiomas should be operated for symptoms well related to the tumor or for bleeding. Psychological requests from the patients should be avoided every time.     

Off-pump coronary artery bypass grafting through sternotomy: for whom?

PURPOSE OF REVIEW: Off-pump coronary artery bypass grafting hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of off-pump coronary artery bypass might be associated with poorer outcomes. Both surgeon-specific and patient-related factors are believed to play roles in the success of off-pump coronary artery bypass. This review sought to elucidate these factors. RECENT FINDINGS: Current prospective data suggest that both techniques have similar rates of mortality but off-pump coronary artery bypass does provide patients with a lower morbidity. Multiple prospective studies suggest a decrease in stroke rates for off-pump coronary artery bypass grafting. There is a consensus that certain patients will have better outcomes if done off-pump. Surgeon experience with the procedure does impact patient outcome. SUMMARY: Though every patient must be dealt with on an individual basis, it would appear that almost any patient is a candidate for off-pump coronary artery bypass and that, given time and an appropriate desire, most any surgeon can perform the procedure.     

Distal pancreatectomy: what is the standard for laparoscopic surgery?

Background/aims:

Distal pancreatectomy (DP) is performed for a range of benign and malignant lesions. Accurate pre-operative diagnosis can be unreliable and morbidity remains high. This study evaluates a 12-year, single-centre experience with open DP to review indications, diagnoses and associated morbidity.

Methods:

Retrospective review of patients who underwent DP at a UK-based tertiary referral centre between 1994 and 2006.

Results:

Sixty-five patients (mean age 49.9 years) had final diagnoses of chronic pancreatitis ± pseudocyst (n= 22), benign cystadenoma (n= 15), neuroendocrine tumour (n= 8), primary pancreatic carcinoma (n= 6) and 14 other conditions. DP performed for presumed cystic neoplasm (n= 24) revealed a correct pre-operative diagnosis in 71% of patients. Histological examination confirmed that 59% of resected cystic tumours were either malignant or had malignant potential. When DP was undertaken for presumed pseudocyst (n= 12), 83% of cases were correctly diagnosed pre-operatively. Overall mortality and morbidity rates were 3% and 39%, respectively, with five patients (8%) developing a clinically significant pancreatic fistula. Ten (17%) patients developed diabetes mellitus and nine (14%) required long-term pancreatic exocrine supplementation.

Conclusions:

Open DP can be performed with acceptable morbidity, low mortality and preservation of pancreatic function in the majority of cases, setting the standard for laparoscopic techniques.     

Early recurrence in patients undergoing curative surgery for colorectal cancer: is it a predictor for poor overall survival?

Purpose

This study evaluated the prognostic value of early recurrence in patients who have undergone curative resection for colorectal cancer.

Methods

A total of 1,159 consecutive patients who underwent curative resection for non-metastatic colorectal cancer from December 1998 to December 2007 were reviewed. The predictive factors for early recurrence postoperatively and the prognostic factors were analyzed.

Results

Of the 1,159 patients, postoperative recurrence was identified in 280 (24.1 %) patients, and 96 (34.3 %) of the 280 patients with recurrence were designed as early recurrence (less than 1 year postoperatively). In multivariate analysis, tumor location, tumor diameter, number of retrieved lymph nodes, and lymphovascular invasion were the independent predictors for early recurrence. The early recurrence group had a significantly lower overall survival rate than that of the non-early recurrence group for both colon cancer (P?<?0.001) and rectal cancer (P?<?0.001). The overall survival rate for stage III tumors significantly differed between the early and non-early recurred patients (P?<?0.001), whereas the rate did not differ between the patients with stage II tumors (P?=?0.364). In multivariate analysis, early recurrence was an independent predictor for unfavorable overall survival. Moreover, differentiation, N category, and postoperative chemotherapy were the independent predictors for overall survival for the patients with both early and overall recurrence.

Conclusion

Poor survival was associated with early postoperative recurrence for patients who underwent curative resection for colorectal cancer. The use of adjuvant chemotherapy prolonged the survival of patients, irrespective of the interval of recurrence.     

Is minimally invasive heart valve surgery a paradigm for the future?

During the past 5 years, there has been considerable progress in the development of less invasive techniques for heart valve surgery. Both aortic and mitral valve surgery can now be performed through small chest wall incisions. Recent evidence confirms patient benefit with minimally invasive heart valve surgery. Although several approaches can be used, a partial upper sternotomy offers several advantages for minimally invasive heart valve surgery.     

Cardiac surgery in the octogenarian: what risks for what benefits?

About 1 to 8% of patients referred for cardiac surgery in industrialised countries are octogenarians. Hospital mortality is high and depends on age, type of surgery and other predictors of death which are female gender, left congestive heart failure, history of myocardial infarction, chronic obstructive lung disease, renal insufficiency, carotid and others vascular diseases. Morbidity is also very high. Besides supraventricular arrhythmias, respiratory failure is the main cause (20 to 30%) of morbidity, followed by cerebrovascular accident and renal failure. Due to this high rate of postoperative events, the length of stay is significantly increased. At follow-up however, excellent functional status and survival rate is afforded by the operative procedure. The main problem remains the selection of patients in order to improve results.