Does multi-vessel off-pump coronary artery bypass grafting reduce post operative morbidity compared to on-pump CABG?

Background Cardiopulmonary bypass (CPB) may contribute to the complications and it is assumed that eliminating cardiopulmonary bypass has the potential of reducing post operative morbidity after coronary artery bypass grafting (CABG). The study was carried out to compare mortality and morbidity in the off-pump and on-pump CABG groups. Methods We prospectively analysed 200 patients undergoing CABG. Group A consists of 100 patients underwent multi-vessel off-pump CABG and group B consists of 100 patients underwent CABG with CPB. The incidence of complications (mortality, re-exploration for bleeding, myocardial infarction, atrial fibrillation, neurological events, new onset renal failure (s. creatinine>1.6 mg/dL) pulmonary complications, length of ICU stay and hospital stay were recorded, analysed and compared. Results OPCAB patients received 2.73±0.61 grafts/patient and on-pump CABG patients received 3.39±0.75 grafts/patient (p value<0.00001). There was no significant statistical difference in mortality, incidence of stroke between OPCAB and CABG with CPB patients. Length of ICU stay was 32.84±4.22 vs 44.85±7.18 hrs (p value<0.00001) and hospital stay was 6.52±0.69 vs 7.94±0.92 days (p value<0.00001) between group A and group B respectively. Incidence of atrial fibrillation was less in OPCAB group 7% vs 12% although it was statistically not significant (p value 0.33). It was observed in our study that there was no significant deference in worsening of existing renal failure between on-pump CABG and OPCAB 6% vs 2% (P value 0.28). Blood utilization was significantly less in OPCAB group (p value<0.001). Conclusion There was no statistically significant difference in terms of mortality, incidence of stroke and new onset renal failure in both groups. But there was lesser incidence of post operative atrial fibrillation, worsening of existing renal failure in off-pump group though statistically not significant. There was significant reduction in blood utilization, length of ICU and hospital stay in OPCAB group.     

Item Response Model Adaptation for Analyzing Data from Different Versions of Parkinson’s Disease Rating Scales

Pharmaceutical Research - Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel technique delivering drugs into the abdominal cavity as an aerosol under high pressure. It is...     

Right internal mammary artery and radial artery composite in situ pedicle graft in coronary artery bypass grafting

Background. The use of two internal mammary artery grafts in coronary artery bypass grafting has been associated with decreased risks of death, reoperation, and angioplasty. However, bilateral internal mammary artery takedown is associated with higher incidence of sternal wound infection, particularly in people with diabetes and in elderly and obese patients. This study was conducted to explore the feasibility of using right internal mammary artery (RIMA) and radial artery (RA) as a composite graft while preserving the distal two thirds of the RIMA to leave the sternal blood supply intact.

Methods. Eighteen patients underwent coronary artery bypass grafting using proximal RIMA and RA composite graft as one of the bypass conduits. The distal two thirds of the RIMA was left intact to preserve sternal blood supply. The graft-free flows of the RIMA and RA composite graft and of the left internal mammary artery graft and the length of the composite graft had been measured. The graft patency and the flow in the distal part of the unharvested RIMA was evaluated postoperatively 2 weeks after the procedure. In 6 of these patients the graft patency was evaluated by selective angiography.

Results. There was no hospital mortality or incidence of perioperative myocardial infarction. None of the patients needed intraaortic balloon pump support postoperatively. There was no sternal wound infection. The vessels grafted were distal right coronary artery (n = 7), posterior descending artery (n = 8), obtuse marginal branches (n = 3), and posterolateral ventricular branch (n = 1); 1 patient received the composite graft as a sequential graft to the posterior descending artery and posterolateral left ventricular branches. The mean graft-free flow of the RIMA and RA composite graft was 98.06 ± 16.93 mL/min compared to left internal mammary artery flows of 55.80 ± 8.99 mL/min. All 16 patients who had a good echo window showed patent grafts when evaluated by two-dimensional echocardiography and color Doppler echocardiography. All of the 6 patients in whom the angiogram was repeated postoperatively showed patent RIMA and RA grafts.

Conclusions. Myocardial revascularization using proximal RIMA and RA in situ pedicle graft was safe in patients with diabetes and in obese and chronic obstructive pulmonary disease patients. This graft was useful to revascularize posterior descending artery, posterolateral ventricular branches of right coronary artery, and obtuse marginal branches where a left internal mammary artery and RA composite graft cannot be used because of technical reasons. Its usage was not associated with sternal wound infection.     

Role of radial artery graft in coronary artery bypass grafting

The use of the radial artery (RA) as a coronary artery bypass graft has assumed a revival and thus a multitude of issues have arisen surrounding the routine and widespread use of this conduit in myocardial revascularization. There has been no uniformity regarding harvest techniques, assessment of the adequacy of hand collateral circulation, antispasm protocols, selection of target vessels, and the site of proximal anastomosis. It is widely believed and practiced that the RA should be harvested as a pedicle graft and preferably be used to bypass critically stenosed (>70% stenosis) coronary arteries. It is used either as a free graft with proximal anastomosis to the ascending aorta or as a composite arterial graft along with the left or right internal thoracic artery. The patency of RA grafts depends on the severity of the target coronary artery stenosis and target artery location rather than its use as an aortocoronary conduit or composite graft. In this article, we reviewed the current knowledge regarding the use of RA grafts as a coronary bypass conduit in an attempt to suggest a few acceptable strategies concerning the above issues in a given clinical scenario.     

A single-centre experience of retroperitoneoscopy using the balloon technique

OBJECTIVE: To report the experience in one centre of the efficacy and safety of retroperitoneal laparoscopic procedures (RLPs). PATIENTS AND METHODS: During 1991-2000, 351 RLPs using the balloon technique were undertaken in 340 patients (mean age 34.9 years, range 4-74); the details and outcome were reviewed. Initial access was by the mini-open digital dissection technique in 152 and by the closed percutaneous technique in the remaining 199 procedures. Patients had not undergone previous retroperitoneal procedures, except for nine who had a percutaneous nephrostomy and eight ipsilateral abdominal surgery. There were 172 renal, seven adrenal, 97 ureteric, 50 gonadal, 13 lymphatic system, three vesical, two autonomic nervous system and seven vertebral RLPs. Nitrous oxide was used for pneumo-insufflation in 103 procedures, instead of CO2. RESULTS: The RLP was successful in 318 of the 351 procedures (90.6%). The operative duration was 0.5-5.5 h, depending on the difficulty of the procedure and the presence or absence of adhesions. The overall incidence of complications was 12.9%, but decreased to 9% for the last 100 procedures. There were only five major complications, e.g. avulsion of the ureter, torn renal pelvis, colonic injury and severe hypotension, but none were related to balloon dissection. The mean blood loss was 37.7 mL and the reason for transfusion in three patients was not operative blood loss but displacement of the ligature in two and severe hypotension after removing a phaeochromocytoma in one. The mean duration of analgesic use was 2.5 days, the hospital stay 3 days and return to work 14 days. CONCLUSION: Retroperitoneal laparoscopy using the balloon technique is a reasonably safe, efficient and reliable minimally invasive procedure. The efficiency, efficacy and safety of RLPs depend more on experience than on the type of access technique, type of balloon or medium used to inflate the balloon. Balloon rupture causes no tissue damage, and expansion to approximately 800 mL in adults is safe if the retroperitoneal space has not previously been invaded. The use of nitrous oxide for pneumo-insufflation in the retroperitoneal space is safe if proper precautions are taken.     

Rare variants of internal thoracic artery in patients with coronary artery disease

The Internal Thoracic Artery (ITA) has been widely used as a conduit in Coronary Artery Bypass Grafting (CABG). We report two patients undergoing CABG for coronary artery disease presented with variants of internal thoracic artery: one patient has hypoplasia of ITAs bilaterally and another patient has hypoplasia of left ITA from the first part of sublcavian artery in association with a normal sized ipsilateral ITA with an aberrant origin from third part of subclavian artery.     

Retroperitoneal laparoscopic pyelolithotomy for staghorn stones

PURPOSE: To establish the feasibility of the retroperitoneal laparoscopic approach for treatment of patients with staghorn renal calculi who are under consideration for an open pyelolithotomy. PATIENTS AND METHODS: Retroperitoneal laparoscopic pyelolithotomy was performed in three patients with impacted staghorn renal calculi between 22 and 45 mm in largest diameter. One of the patients also had multiple caliceal stones. These patients wanted an open procedure but had agreed to have their stone removal done laparoscopically in view of our experience. The previously described retroperitoneal laparoscopic approach was used, and the handling of some of the specific problems in such patients is described in the text. RESULTS AND CONCLUSION: The stones were removed successfully in all the three patients, and there were no complications. Although no definitive conclusion can be drawn from this small series, the paper shows the feasibility of the retroperitoneal laparoscopic approach in a select group of patients with staghorn renal calculi.     

Mini-access for retroperitoneal laparoscopy

The purpose of this study was to establish the feasibility of primary mini-access to the retroperitoneal space to perform certain retroperitoneoscopic procedures in which an enlarged port is not required for extraction of the specimen. Mini-laparoscopy or needlescopic laparoscopy has been performed in the past via the transperitoneal route, but this has not yet been reported for a retroperitoneoscopic procedure. Through a 5-mm primary access and 3- or 5-mm secondary ports, retroperitoneoscopic surgery was performed in seven adults for ureterolithotomy, renal biopsy, simple nephrectomy, nephropexy, cyst decortication, or drainage of a subphrenic abscess. The access technique used was a mini-version of a previously described percutaneous access technique with some modifications. The retroperitoneoscopic procedure was successful in all seven patients, and no complications developed. The operative time, blood loss, analgesic intake, and length of hospital stay were comparable with those of a standard retroperitoneoscopic procedure. However, the cosmetic results were better. Mini-retroperitoneoscopy is feasible and is a better alternative for patients in whom the whole procedure can be performed through 5-mm or smaller ports.     

Laparoscopic ureterolithotomy: technical considerations and long-term follow-up

OBJECTIVE: To analyse the technical details and the long-term results of laparoscopic ureterolithotomy. PATIENTS AND METHODS: Laparoscopic ureterolithotomy was undertaken in 101 patients between 1991 and 2001; in only one patient with retroperitoneal fibrous adhesions was the procedure transperitoneal, being retroperitoneal in all the others, using Gaur's balloon retroperitoneoscopy. The mean (range) stone size was 16 (10-47) mm, and the stones were in the upper ureter in 75, mid-ureter in 11 and lower ureter in 15 patients. Nine patients had more than one stone, the maximum being six, in a megaureter. Most were impacted for > 2 months, the maximum being 240 months. RESULTS: Laparoscopic ureterolithotomy was successful in 93 patients, with the eight failures being mostly early in the series. The mean operative duration was 79 min (66 min when the ureter was left open and 92 min when it was sutured). The overall mean duration of urinary leakage was 5.5 days, which was reduced to 3.2 days by stenting and suturing the ureter. The mean (range) blood loss was 25 (5-100) mL. The overall complication rate was high (31%) because of prolonged urinary leakage in 20 patients. No patient required morphine for pain relief and the mean for oral analgesic use was 2.5 days. The mean hospital stay was 3.5 days and that for resuming work 14 (7-28) days. CONCLUSIONS: Laparoscopic ureterolithotomy by the retroperitoneal approach is a safe and reliable minimally invasive procedure. Although its role as a salvage procedure for failed extracorporeal shock wave lithotripsy and ureteroscopy is undisputed, in selected patients with large chronically impacted ureteric stones and particularly with solitary kidneys, it may be considered the first-line treatment.