The heavy price of conversion from laparoscopic to open procedures for emergent cholecystectomies

Background

Laparoscopic cholecystectomy (LC) is the standard operative intervention for gallbladder disease. Complications may necessitate conversion to an open cholecystectomy (OC). This study aims to determine the cost-consequences of laparoscopic-to-open conversion using a nationally-representative sample.

“Open” approach to aortic arch aneurysm repair

Aortic arch aneurysm is a relatively rare entity in cardiac surgery. Repair of such aneurysms, either in isolation or combined with other cardiac procedures, remains a challenging task. The need to produce a relatively bloodless surgical field with circulatory arrest, while at the same time protecting the brain, is the hallmark of this challenge. However, a clear understanding of the topic allows a better and less morbid approach to such a complex surgery.Literature has shown the advantage of selective cerebral perfusion techniques in comparison with only circulatory arrest. Ability to perfuse the brain has allowed circulatory arrest temperatures at moderate hypothermia without the need for deep hypothermia. Even though cannulation site selection appears to be a minor issue, literature has shown that the subclavian/axillary route has the best outcomes and that femoral cannulation should only be reserved for no access patients. Although different techniques for arch anastomosis have been described, we routinely perform the distal first technique as we find it to be less cumbersome and easiest to reproduce.In this review our aim is to outline a systematic approach to aortic arch surgery. Starting with indications for intervention and proceeding with approaches on site of cannulation, approaches to brain protection with hypothermia and selective cerebral perfusion and finally surgical steps in performing the distal and arch vessels anastomosis.     

Thromboinflammatory response and predictors of outcomes in patients undergoing transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has been increasingly used to treat patients with symptomatic aortic stenosis. Despite improvements in valve deployment, patients that have undergone TAVR are at high risk for major adverse events following the procedure. Blood cell numbers, platelet function, and biomarkers of systemic inflammation were analyzed in 58 patients undergoing TAVR with the Edward’s SAPIEN valve. Following valve deployment, platelet count and agonist-induced platelet activity declined and plasma markers of systemic inflammation (interleukin-6 and S100A8/A9) increased. Baseline platelet activity prior to TAVR correlated with perioperative changes plasma interleukin-6 levels. Moreover, perioperative changes in plasma inflammatory markers predicted the decline in platelet count in the days following the TAVR procedure. Additionally, a significant effect of gender on platelet count following TAVR and was observed. Finally, post-procedural mortality was associated with sustained thrombocytopenia after TAVR. Our findings suggest that TAVR elicits a thromboinflammatory state that may contribute to post-procedural thrombocytopenia. Importantly, our results add to the growing body of literature that suggests the thromboinflammatory changes that occur early after TAVR may predict long-term outcomes.     

Is Conservative Management for Gastric Perforation Secondary to Intragastric Balloon Possible? Case Report and Review of Literature

Intragastric balloon (IGB) is one of the available options for the management of morbid obesity. The procedure is generally safe and of moderate efficacy in most of the cases. One of the reported complications of IGB is gastric perforation. The management of this complication is classically surgical. To our knowledge, conservative management for gastric perforation secondary to IGB has not been reported. A 27-year-old female patient presented with sudden abdominal pain in the left upper quadrant, 2 months after having an IGB placed. The provisional diagnosis was gastric perforation. Balloon extraction was performed and a conservative management of the gastric perforation was pursued successfully. We therefore propose that this sort of management might be adopted in carefully selected cases.     

Treatment of two newborns with esophageal atresia and distal tracheoesophageal fistula complicated by gastric perforation: choosing the simple way

Abstract

Objective: Gastric distention and perforation are possible results in a preterm newborn with esophageal atresia and distal tracheoesophageal fistula, especially when there is a need for mechanical ventilatory support. The results of the reported cases treated with emergency thoracotomy and fistula ligation after gastrostomy are not very satisfactory. Sometimes simple temporary solutions can be useful for stabilization and allow safety for required surgical treatment for later.

Patient and methods: Two preterm newborns with esophageal atresia and distal tracheoesophageal fistula complicated by gastric perforation were reported.

Results: Both of the patients were initially treated with a simple peritoneal drainage and, then the definitive operations were performed without any problem in stabilized patients.

Conclusion: Performing fistula ligation or occlusion as an initial treatment in patients with impaired cardiac and respiratory functions may worsen the status of the patient. In such cases, it could be better to perform simple interventions first to facilitate subsequent treatments.     

Frequency of Mammary Artery Coiling in Single-Ventricle Patients and Future Coronary Artery Grafting

Pre-Fontan coil closure of aorto-pulmonary collaterals decreases single-ventricle volume load and improves outcome. Coiling of right and left internal mammary arteries may present a challenge to cardiothoracic surgery teams caring for these patients when future coronary artery bypass grafting is needed for SV patients. The goal of this study was to determine the frequency of internal mammary artery coil closure in SV patients in a single tertiary care center. A retrospective review of all pediatric single-ventricle patients who underwent cardiac catheterization between March 2009 and October 2015 at Rush Center for Congenital Heart Disease was performed. Fifty-one patients’ charts were reviewed. Twenty-five patients received coil closure of one or more internal mammary artery (coil group) and 26 received no coil closure (no-coil group). In the coil group, 21 (84 %) had their collateral vessels coiled in the pre-Fontan period and 4 (16 %) had their vessels coiled in the post-Fontan period. In the coil group, 18 (72 %) had their right internal mammary artery coiled and 7 (28 %) had both right and left internal mammary arteries coiled. None of the coil group had isolated coil closure of the left internal mammary artery. This study is the first to verify the frequency of right and/or left internal mammary artery coil closure in SV patients and the potential impact on future coronary artery bypass grafting. Extensive peri-Fontan coiling of the internal mammary arteries presents a significant potential challenge for subsequent management of SV patients as older adults.