Early and late outcomes of coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stents for dialysis patients

Abstract Background: Advances in percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) have impacted clinical practice. However, the efficacy of DES for dialysis patients still remains controversial. This study compares the early and long‐term clinical outcomes of coronary artery bypass grafting (CABG) and PCI with DES in dialysis patients. Methods: A retrospective review was performed in 125 dialysis patients treated between 2004 and 2007. Fifty‐eight patients underwent CABG and 67 underwent PCI with DES. The overall death, cardiac death, and cardiac‐related event rates were analyzed using the Kaplan‐Meier method. For the risk‐adjusted comparisons, multivariable logistic and Cox regression analyses were used. Results: The preoperative characteristics of the patients were similar except for the ejection fraction (p = 0.002) and the number of diseased vessels (p < 0.001). The 30‐day mortality was 0 in both groups. The overall survival rates at one, three, and five years were 84.2%, 64.7%, and 56.2% in CABG group and 88.2%, 75.5%, and 61.7% in DES group, respectively (p = 0.202). The rates of freedom from cardiac‐related events at one, three, and five years were 76.6%, 68.1%, and 48.6%, and 63.0%, 31.4%, and 0% in CABG and DES groups (p < 0.001), respectively, including seven (10%) late thromboses in the DES group. Although the risk‐adjusted analysis showed no significant difference for overall and cardiac death rates, the rates of cardiac‐related events and graft/stent failure were significantly higher in the DES group. Conclusions: CABG is superior for revascularization in dialysis patients compared with PCI using DES in terms of freedom from cardiac‐related events. (J Card Surg 2012;27:281‐287)     

A case of combined glossopharyngeal and trigeminal neuralgia

It is well-known that idiopathic neuralgias of the trigeminal and glossopharyngeal nerves are caused by vascular compression at the root entry zone of the cranial nerves. Because they are functional diseases, initial treatment is medical, especially with carbamazepine. However, if medical therapy fails to adequately manage the pain, microvascular decompression (MVD) is prescribed. Glossopharyngeal neuralgia is rare, and combined trigeminal and glossopharyngeal neuralgia is an extremely rare disorder. A 70-year-old woman presented herself to Hokkaido Neurosurgical Memorial Hospital because of paroxysms of lancinating pain in her left pharynx and another lancinating pain in her left cheek. Carbamazepine, which was prescribed at another hospital, favorably relieved the pain; however, drug eruption compelled her to discontinue the medication. The multi-volume method revealed that a root entry zone of the left glossopharyngeal nerve was compressed by the left posterior inferior cerebellar artery, and the left trigeminal artery was compressed by the left superior cerebellar artery. MVD for both nerves was performed employing a left lateral suboccipital craniotomy. She experienced complete relief of pain immediately after MVD. Combined trigeminal and glossopharyngeal neuralgia is extremely rare, but some groups noted a relatively high incidence of concurrent trigeminal neuralgia in patients with glossopharyngeal neuralgia up until the 1970's. Glossopharyngeal neuralgia includes pain near the gonion; therefore, there is an overlap of symptoms between glossopharyngeal and trigeminal neuralgias. By virtue of recent progress in imaging technology, minute preoperative evaluations of microvascular compression are possible. Until the 1970's, there might have been some misunderstanding regarding the overlap of symptoms because of lack of the concept of microvascular compression as a cause of neuralgia and rudimentary imaging technology. Minute evaluations of both symptoms and imaging are very important.     

Experience with laparoscopic splenectomy for ABO-incompatible living related renal transplantation

PURPOSE: To determine whether laparoscopic splenectomy for ABO-incompatible living related renal transplantation is safe and effective. PATIENTS AND METHODS: From July 2000 to May 2002, laparoscopic splenectomy was performed on the day of transplantation in 10 patients undergoing ABO-incompatible living related renal transplantation. Perioperative and postoperative data, including operative time, blood loss, and complications, were evaluated. RESULTS: The mean operative time was 79 minutes. Intraoperative blood loss ranged from 25 mL to 600 mL (mean 130 mL). Transfusion was not required in any case. One patient required open conversion because of bleeding from the splenic hilum. The serum amylase value was slightly elevated postoperatively in four patients but normalized with conservative treatment. One patient had bleeding from a trocar port wound, which was likewise treated conservatively. No complications, including postoperative renal dysfunction or fatal infections, that were considered attributable to the laparoscopic procedure were noted. CONCLUSIONS: Laparoscopic splenectomy performed simultaneously with renal transplantation is a safe and efficacious procedure for ABO-incompatible living related renal transplantation.     

Postoperative cytology for drained fluid from the pancreatic bed after "curative" resection of pancreatic cancers: does it predict both the patient's prognosis and the site of cancer recurrence?

OBJECTIVE: To evaluate the postoperative cytology of drained fluid from the pancreatic bed as a predictive indicator of local recurrence after curative (R0) resection of pancreatic cancer. SUMMARY BACKGROUND DATA: The pancreatic bed offers a common site of cancer recurrence (local recurrence), even after curative (R0) resection is performed for pancreatic cancer. If local recurrence is thereby predicted precisely, soon after surgery, we have a chance to treat it by adding radiation or some other locoregional therapy before it can grow or spread beyond the pancreatic bed. However, there have been no previous reports of cytology performed on the drained fluid after pancreatectomy. METHODS: This study includes 94 patients who had shown negative results in the peritoneal washing cytology before resection and subsequently received pancreatectomies for pancreatic tumors. They consisted of 12 benign tumors, 17 noninvasive or minimally invasive carcinomas and 65 invasive ductal carcinomas (R0 = 58; R1/2 = 7). Postoperatively, the drained fluid from the pancreatic bed was collected for 24 hours and used for cytologic examination. The cytologic results were examined in association with the histopathology of the resected tumor, patient's survival, and mode of cancer recurrence, including local recurrence. RESULTS: Patients with benign tumors or noninvasive/minimally invasive carcinomas had negative result in cytology, and none of them have died of local recurrence (limited to the pancreatic bed) to date. However, patients with invasive ductal carcinoma revealed higher cytology-positive rates: 28% (16/58) in curative (R0) resection; and 71% (5/7) in noncurative (R1/2) resection. Among 58 patients with R0 resection, the 3-year survival rate was 14% in 16 cytology-positive patients and 55% in 42 cytology-negative patients (P < 0.05). The 3-year cumulative rate of local recurrence was 85% and 23%, respectively (P < 0.05). Compared with other histopathologic parameters obtained from the resected specimens, the drain cytology was more specific in predicting the subsequent development of local recurrence. CONCLUSIONS: Drain-cytology was a quick examination that enabled us to specifically indicate both minute residual cancer and subsequent development of local recurrence even after R0 resection of pancreatic cancer.     

Comparison of plasma levels of mature adrenomedullin and natriuretic peptide as markers of cardiac function in hemodialysis patients with coronary artery disease

BACKGROUND: It has been suggested that, like ANP and BNP, high plasma levels of mature adrenomedullin (mAM) indirectly reflect the severity of heart failure or renal failure. However, the relationship between mAM levels and hemodynamics and cardiac function has not been examined in hemodialysis (HD) patients with coronary artery disease (CAD). The best marker, among mAM, ANP and BNP, for left-ventricular function in those patients is also unclear. PATIENTS AND METHODS: Plasma levels of mAM, total AM (tAM), ANP and BNP were determined before HD in chronic HD patients with CAD (group 1; n = 17) and were compared with those of HD patients without cardiac disease (group 2; n = 22). We examined their relationship to hemodynamics and cardiac function in group 1 using data obtained by cardiac catheterization. RESULTS: Plasma levels of ANP and BNP were significantly higher in group 1 than in group 2, but there was no significant difference in plasma levels of mAM and tAM between the two patient groups. Plasma levels of both mAM and tAM significantly correlated with right atrial pressure (RAP), and only plasma tAM levels correlated with pulmonary artery pressure (PAP) and pulmonary artery wedge pressure (PAWP). However, no correlations were found between levels of the two forms of AM and ejection fraction (EF). In contrast, plasma ANP and BNP levels significantly correlated with both PAP and PAWP, and also with EF, although they did not correlate with RAP. The correlation of PAP and PAWP with ANP and BNP levels was closer than that with tAM levels. The most significant correlation was between BNP levels and EF (r = -0.756, p < 0.0001). CONCLUSIONS: Our results suggest that the mAM level may be less useful than natriuretic peptide levels as a marker of cardiac function in HD patients with CAD, and that the BNP level might be the best indicator of left-ventricular function. In addition, cardiac disease such as CAD may have a minor impact on mAM levels compared to renal failure.     

Ultraflex expandable stents for the management of air leaks.

Postoperative empyema and aspergillosis were diagnosed in a 66-year-old man. Since non-operative therapy was not effective, we performed surgery. On the 8th postoperative day, a covered Ultraflex expandable stent (Boston Scientific, Galway, Ireland) was implanted to make a one-way airway for blocking a major air leak from a bronchopleural fistula causing respiratory distress. His general condition improved gradually, and he was discharged 30 days after stenting. In conclusion, we used a covered Ultraflex expandable stent to make an airway to block an air leak. This may be a new application for this stent.     

Characteristics and timing of recurrence during postoperative surveillance after curative resection for lung adenocarcinoma

Purpose

To establish the most effective methods of postoperative surveillance to detect early recurrence of lung adenocarcinoma.

Methods

The subjects of this retrospective study were 485 patients with p-stage I–III lung adenocarcinoma, who underwent postoperative surveillance. We examined the sites and detection modes of recurrence and calculated the recurrence-free probabilities. Patients with stage I disease were divided into low- and high-risk recurrence groups using a risk score calculated by assigning points proportional to risk factor regression coefficients.

Results

Of the 112 patients with recurrence, 86 had intrathoracic recurrence. Routine computed tomography (CT) revealed recurrence in 60 patients. The recurrence-free probability curves showed that 95% of recurrences were identified within the first 4 years after resection in patients with stage II/III disease. In patients with stage I disease, the predictors of recurrence included male sex, positive pleural lavage cytology, moderate-to-poor differentiation, and visceral pleural invasion. Postoperative recurrences were detected throughout the follow-up period in the high-risk group.

Conclusions

Routine chest CT plays an important role in the postoperative surveillance of lung adenocarcinoma. We recommend intensive follow-up during the early post-resection period for patients with advanced stage disease and long-term follow-up for high-risk patients with stage I disease.

     

The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study

Purpose

Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors.

Methods

Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade.

Results

Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24–48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02).

Conclusions

In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.

     

Minimally Invasive 360° Fusion Using a Combination of INFIX and Minimally Invasive Spinopelvic Fixation by Intraoperative Computed Tomography Navigation for Unstable Pelvic Ring Fracture: A Technical Note

Objective

Fluoroscopy is often used in the surgery of unstable pelvic ring fractures, and improved safety in implant placement is an issue. An anterior subcutaneous pelvic fixator (INFIX) combined with a percutaneous screw has been reported to be a minimally invasive and effective surgical technique for unstable pelvic ring injuries. However, although percutaneous screw fixation is minimally invasive, its indications for fracture fixation and fractures with large fragment displacements in the vertical plane remain controversial. Therefore, this technical note aims to describe a new technique for unstable pelvic ring fractures.

Methods

We describe a 360° fusion of the pelvic ring to treat unstable pelvic ring fractures, including vertical shear pelvic ring fractures, using an intraoperative CT navigation system. Seven patients were treated with 360° fusion for type C pelvic ring fractures. In surgery, after reducing the fracture with external fixation, intraoperative CT navigation is used to perform a 360° fusion with INFIX and minimally invasive surgical spinopelvic fixation (MIS-SPF). We will introduce a typical case and explain the procedure.

Results

A 360° fixation was performed, and no perioperative complications were noted. The mean blood loss was 253.2 ± 141.0 mL, and the mean operative time was 224.3 ± 67.4 min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants.

Conclusions

MIS-SPF has a strong fixation force and helps reduce fractures' horizontal and vertical planes. In addition, 360° fusion with intraoperative CT navigation may help treat unstable pelvic ring fractures.