Conversions in off-pump coronary artery bypass grafting: analysis and outcome

Off-pump coronary artery bypass graft [CABG] surgery is supposed to reduce perioperative mortality and morbidity compared with on-pump coronary bypass graft surgery. The causes of hemodynamic collapse during off-pump coronary artery bypass [OPCAB] remain scarcely defined. We present an analysis of 7 cases who were converted to conventional CABG due to sustained hemodynamic collapse or else, during elective off-pump CABG. During a 12-month period, we performed 77 elective OPCAB procedures through a sternotomy, constituting 56.2% of the total CABG procedures performed. Six patients [1.6%] experienced hemodynamic collapse intra-operatively and one [0.23%] electively requiring immediate cardiopulmonary bypass. Preoperative characteristics, intraoperative data, and postoperative outcome were retrospectively reviewed. In all cases, improvements in intra-operative technique and/or judgment could be made retrospectively. Six of these patients were converted in emergency, and on electively to cardiopulmonary bypass. Three [3/77] patients had an unstable course and did not survive operation. The causes of hemodynamic collapse during elective OPCAB were ischemic, mechanical, or a combination of both. Based on these results, strong consideration should be given for a planned strategy of CPB in high risk patients

Post-cholecystectomy biliary injuries: diagnosis and management

To evaluate the management strategies following Bile Duct Injuries. Retrospective and prospective analysis from July 2002 to Oct. 2005. Surgical Ward-2, Jinnah Postgraduate Medical Centre, Karachi. All patients who were admitted with Iatrogenic Biliary injuries. The patients were clarked and their clinical features noted. After appropriate preparations they were treated on the basis of Bismuth Classification. A total of 21 patients presented with Iatrogenic Biliary injuries over a period of three years. There were 15 females and six males with a median age of 40 years. Fourteen patients had laparoscopic cholecystectomy while seven had open cholecystectomy. Six cases belonged to our unit while 15 were referred from other institutes. Sixteen patients presented with biliary leak, out of which two resolved, two had ultrasound guided aspiration and two ERCP stenting done, while 10 underwent peritoneal lavage with drain placement. One patient from lavage group required ERCP stenting while one patient that underwent stenting initially developed stricture and had to undergo Roux-en-Y hepaticojejunostomy. Five patients had biliary stricture at presentation, three were Bismuth Type I, one was Type III and one Type IV. These patients were treated with Roux-en-Y hepaticojejunostomy. Two had to undergo re-exploration, one needed lavage and the other revision hepaticojejunostomy. Three patients expired in the early postoperative period. Strategies need to be developed for dealing with bile duct injuries, with a view to reduce morbidity and mortality as early recognition and timely management improves the outcome of these patients