Digital video recording of cardiac surgical procedures

PURPOSE: We attempted to find a method of reducing time and effort for recording videos of cardiac surgical procedures. DESCRIPTION: A camera mounting arm designed by us provided a properly fixed digital camera location for undisturbed recording. The camera and its remote control unit provided an opportunity for the surgeon to record only the steps of the operation without need for editing. EVALUATION: Digital videos produced by this method required no additional time from the surgeon except to record the commentary at leisure. The video recorded was of excellent quality and provided a well-focused recording of the steps of the operation. CONCLUSIONS: The technique described for video recording of cardiac surgical procedures provides a time-saving and easy method for good reproduction of surgical procedures.     

The current surgical management of carotid body paragangliomas.

To determine if recent trends in evaluation and therapy have contributed to the successful surgical management of carotid body paragangliomas, we reviewed our experience over the past decade. Nineteen carotid body paragangliomas were identified in 17 patients. Eleven patients underwent complete, preoperative embolization of their afferent arteries with one complication. Calculated carotid body paragangliomas surface areas did not differ between the embolized 64.6 +/- 43.3 cm2 and nonembolized 63.0 +/- 57.9 cm2 lesions. Intraoperative blood loss was lower (p = 0.02) in the patients treated with embolization (372 +/- 213 ml) compared with their cohorts (609 +/- 564 ml). However, the operative times were equivalent 4.1 hours versus 4.5 hours in both groups. Intraoperative electroencephalographic (EEG) monitoring was used in 10 patients; in one patient the EEG indicated intraoperative thrombosis of the carotid artery, which was successfully treated by thrombectomy without complications. Two patients required carotid bifurcation resection and vascular reconstruction to remove the entire tumor; a late stroke manifested by contralateral hand weakness developed in one of these patients. The incidence of cranial nerve injury was low at 16%, with one transient ramus mandibularis paresis and two instances of vocal cord dysfunction. Two additional patients had a postoperative Horner's syndrome. We conclude that by diminishing intraoperative blood loss through complete and careful preoperative embolization and use of intraoperative EEG monitoring along with careful surgical technique, the complications associated with this challenging operation are facilitated and diminished.     

Contemporary surgical management of pheochromocytoma

BACKGROUND: The availability of laparoscopic adrenalectomy led us to review our experience and management of adrenal and extraadrenal pheochromocytoma. METHODS: Seventeen patients undergoing pheochromocytoma resection from January 1997 to August 2001 were categorized as open, laparoscopic, or laparoscopic assisted depending on the surgical approach. Hospital records were reviewed. RESULTS: There was no significant difference between the groups in patient age, weight or preoperative blockade. Operative times for open, laparoscopic, and laparoscopic assisted adrenalectomies were 202, 218, and 260 minutes, respectively. Estimated blood loss was 562 cc, 187 cc, and 925 cc. The average hospital length of stay was 6.2, 3.0, and 5.8 days. CONCLUSIONS: Laparoscopic removal resulted in longer operative times than open, but less operative blood loss and a shorter hospital stay. The laparoscopic assisted approach did not save time nor did it lead to earlier discharge. Laparoscopic adrenalectomy was comparable to the open approach, and is preferential in tumors less than 6 cm. An open approach remains our choice for larger or extraadrenal tumors.     

Successful surgical treatment for dilated cardiomyopathy with cardiac sarcoidosis

We report a surgical case of severe left ventricular dysfunction due to cardiac sarcoidosis. A 45-year-old man who underwent pacemaker implantation for complete atrioventricular block was admitted to the hospital because of dyspnea due to congestive heart failure. Echocardiography revealed a left ventricular ejection fraction of 11%, with severe mitral insufficiency and thinning of the ventricular septum. He was successfully treated by anteroseptal ventricular exclusion, mitral and tricuspid annuloplasty, and bi-ventricular pacing. Postoperative pathologic study revealed noncaseating granulomas. The patient was referred to a cardiologist for further treatment with prednisone.     

A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients

BACKGROUND: Optimal antimicrobial prophylaxis for the pediatric cardiac surgical patient is unknown. We have reviewed our experience with more than 4,000 pediatric cardiac surgical patients at the University of Michigan to evaluate antibiotic prophylaxis regimens. METHODS: Three antibiotic prophylaxis protocols were serially used during a 6-year period: Protocol 1 (n = 786): cefazolin was administered before operation and continued as long as thoracostomy tubes or central venous catheters were present; Protocol 2 (n = 1095): cefazolin was discontinued 48 hours postoperatively, regardless of the presence of tubes or catheters; Protocol 3 (n = 2039): cefazolin was continued as long as thoracostomy tubes were present, but not for central venous catheters. Patients with an open chest postoperatively received vancomycin and gentamicin until chest closure. This was identical during all three protocols. We retrospectively determined the rate of surgical site infections and unrelated bloodstream infections (the latter for both cardiac medical and surgical patients) for the three protocols. RESULTS: Surgical site infections per 100 operations for protocols 1, 2, and 3 was 2.04, 6.58, and 1.67, respectively (p < 0.05 for protocol 2 versus protocols 1 and 3). The mean age of patients with a surgical site infection ranged from 12 to 15.4 months. Patients with an open chest had a higher rate of surgical site infection (18.8% for protocol 2 and 9.3% for protocol 3). Bloodstream infections per 1,000 patient days for protocols 1, 2, and 3 were 2.18, 6.51, and 5.02, respectively (p < 0.05 protocol 1 versus protocols 2 and 3). CONCLUSIONS: These data suggest that pediatric cardiac surgical patients may benefit from prophylactic antibiotics as long as thoracostomy tubes are in place.     

Contemporary surgical management of HIV-associated facial lipoatrophy

OBJECTIVES: The purpose of this study is to describe our experience with facial volume restoration in 39 HIV-associated facial lipoatrophy patients, and formulate a treatment algorithm that can be utilized for these patients based on their disease severity. METHODS: Preoperative and postoperative photographs were evaluated by 2 experienced facial plastic surgeons using grading scales. The reviewers' scores were then compared and the distribution of scores was analyzed. RESULTS: Thirty-nine patients underwent malar silastic implantation. Seven patients required postoperative adjuvant filler injection. Most patients' results were rated good to excellent. There were 4 late complications. CONCLUSION: HIV-associated facial lipoatrophy is a socially disabling condition that causes noticeable disfigurement and stigmatizes the patient. We demonstrate the importance of combining a reliable grading scale with a strategic treatment algorithm that utilizes multiple modalities for volume restoration. EBM RATING: C-4.     

Contemporary surgical management of renovascular disease.

To examine the treatment methods and early results of renovascular repair in our contemporary patient population, we reviewed our surgical experience during a recent 54-month period. From January 1987 to July 1991, 200 patients ranging in age from 5 to 80 years (mean, 56 years) were operated on for correction of nonatherosclerotic (43 patients) and atherosclerotic (157 patients) renovascular disease. The group included 92 men and 108 women, with blood pressures ranging from 300/198 mm Hg to 120/70 mm Hg (mean, 205/113 mm Hg). Defined by preoperative serum creatinine, 129 patients (65%) had evidence of renal insufficiency (Cr greater than or equal to 1.3 mg/dl), whereas 71 patients (36%) had severe renal insufficiency (Cr greater than 2.0 mg/dl; 11 patients were dependent on dialysis). One hundred forty-seven patients with atherosclerotic renovascular disease (94%) demonstrated organ-specific atherosclerotic damage. Operative management of 291 kidneys included unilateral renal artery repair in 117 patients (58%), bilateral repair in 78 patients (39%), and primary nephrectomy in five patients (2.5%). Simultaneous aortic reconstruction was required in 64 patients (32%). There were five operative deaths (2.5% mortality rate) and four occluded renovascular repairs (1.4% primary failure) within 30 days of surgery. Hypertension was considered cured in 21% and improved in 70% of 195 operative survivors. In 70 patients with severe renal insufficiency before operation, estimated glomerular filtration rate was improved in 49% (8 of 11 patients removed from dialysis), unchanged in 36%, and worsened in 15%. Renal function response was significantly influenced by the site of disease and the operation. Twenty-six additional postoperative deaths occurred during follow-up (range, 6 to 58 months; mean, 24.4 months). Extreme atherosclerotic-renovascular disease, preoperative renal insufficiency, failure to improve renal function, and progression to dependence on dialysis after operation were associated with follow-up deaths. Although most patients had a beneficial outcome, failure to improve extreme renal insufficiency was associated with a rapid rate of death during a relatively short follow-up period.