Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother?

Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.

Simple incision: a safe and definitive procedure for congenital duodenal diaphragm.

BACKGROUND: Duodenal diaphragms generally are treated by either a duodeno-duodenostomy or excision. The former is a bypass procedure that involves a major anastomosis with its inherent postoperative problems, whereas the latter may result in inadvertent damage to the biliary and pancreatic ducts. To circumvent these problems, the authors used the technique of incision of the diaphragm on its lateral aspect. METHODS: Medical records of five children who underwent surgery for a perforate duodenal diaphragm during the period of 1992 through 1994 were reviewed retrospectively. All patients underwent a similar procedure. A longitudinal duodenotomy was made and the diaphragm incised on its anterolateral aspect. The cut edges of the diaphragm were oversewn, and the duodenotomy closed in "Heineke-Mikulicz" fashion. RESULTS: At a follow-up ranging from 1 to 3 years, all patients are growing normally and remain free of any obstructive symptoms. CONCLUSIONS: This simplified approach is a safe and physiological way of restoring the duodenal continuity and is associated with a highly satisfactory outcome.

Currarino's triad: an unusual cause of constipation in children.

A 6-year-old girl presented with intractable constipation. On investigation, she was found to have an association of anorectal stenosis, anterior sacral defect, and anterior meningocoele (Currarino's triad). The meningocoele was excised and a Duhamel pull-through procedure performed after resection of a massively distended rectosigmoid. Post-operatively, she started having spontaneous bowel action. Early diagnosis and management is recommended to avoid the high mortality and morbidity associated with this condition.

Rectal ectasia associated with anorectal anomalies.

Rectal ectasia may be associated with anorectal anomalies. If not recognized at the time of surgical reconstruction it may lead to megarectosigmoid, resulting in severe constipation and overflow incontinence postoperatively. The authors treated four patients presenting with this condition. One patient born with a low anorectal anomaly and two with high anorectal anomalies experienced intractable constipation caused by megarectum despite otherwise adequate primary reconstructive procedures. A fourth patient had rectal stenosis in association with megarectosigmoid. The ectatic megarectum had to be resected in all the patients to achieve normal bowel actions. The authors feel that resection or tailoring of the ectatic segment should be an integral part of the primary reconstructive procedure.

Neural cell adhesion molecule (NCAM) expression in nerves and muscle of developing human large bowel.

Most studies of neural cell adhesion molecule (NCAM) in human musculature are devoted to either developing or adult skeletal and cardiac muscle. The aim of this study was to determine the pattern of NCAM expression in the intestinal musculature of the developing human large bowel. In specimens of large bowel from foetuses (gestational age 8-20 weeks), we examined the immunohistochemical localisation of NCAM in parallel to those of alpha-smooth muscle actin and desmin. Within the developing neural complex, NCAM was expressed at all stages investigated. In intestinal muscle at 8 weeks, immunoreactivity for all antisera was restricted to the muscularis propria. The differentiating muscularis mucosae was demonstrated first at 15 weeks by immunostaining for alpha-smooth muscle actin, and this expression was followed by that of NCAM and desmin at 17 and 19 weeks, respectively. At 20 weeks, NCAM immunoreactivity in the external muscle was intense at the inner border of the circular muscle, with its concentration decreasing towards the outer margin of the muscular wall, whereas alpha-smooth muscle actin and desmin were uniformly distributed in all muscle layers. NCAM is expressed by nerves and muscle of developing human large intestine. Its appearance follows a predetermined pattern, which implies its relevance to the differentiation of intestinal muscle layers.

Oronasopharyngeal teratomas.

Oronasopharyngeal teratomas are rare tumours that usually present in the neonatal period with airway obstruction. Management should include prompt establishment of the airway and early excision. Complete excision is recommended, which may require more than one operation, but multilating surgery should be avoided as the malignant potential of these tumours is extremely low. We describe our experience with three patients along with a literature review.

Rectal atresia and stenosis.

Rectal atresia and stenosis are rare and peculiar anorectal malformations for which many and varied surgical procedures have been described, ranging from simple perforation of the atresia to extensive sacro-abdomino-perineal pull-through operations. The results of the operations have been generally unsatisfactory, chronic constipation being a common postoperative feature. In the authors' experience, the Duhamel pull-through is the operation of choice for this problem.

Scattered radiation in a neonatal surgical unit.

We studied the doses of "scattered" received by neonates in a Neonatal Surgical Unit by placing thermoluminescent dosemeters in various positions expect the direct beam. Doses of "scattered" radiation received by neonates as a results of exposure of their neighbours to X-ray examinations were found to be negligible. Sick neonates need not be moved from their neighbours undergoing exposure to X-rays.

Colonic stricture in a boy with cystic fibrosis.

Many problems may arise within the gastrointestinal tract of patients with cystic fibrosis. We report a new cause of subacute intestinal obstruction due to a fibrotic stricture of the ascending colon in a child with cystic fibrosis. Treatment was with a right hemicolectomy. There has been no recurrence after nine months follow-up. Recent similar cases suggest that this new pathology is linked to the use of enteric-coated high-strength pancreatin microspheres.

Management of alimentary tract duplication in children.

Duplication of the alimentary tract is rare but potentially dangerous. Five of 72 children with alimentary tract duplication treated between 1973 and 1992 died from postoperative complications; a further ten required more than one operation. Ileal duplications were the commonest, occurring in 16 patients (22 per cent). Thoracoabdominal duplications were the most complicated and responsible for much of the overall morbidity and mortality. Surgical complications were related to the size and location of the duplication, communication with the gastrointestinal tract or vertebral canal, presence of heterotopic gastric mucosa and involvement of mesenteric vessels. Complete excision of the duplication should be possible in most cases.

Meconium ileus due to extensive intestinal aganglionosis.

Seven full-term infants with aganglionosis extending into the small bowel presented with clinical, radiological, and operative features of meconium ileus. Misdiagnosis resulted in inappropriate treatment. The correct diagnosis was eventually established by rectal suction biopsy, mostly after either recurrent intestinal obstruction or stomal dysfunction, and after cystic fibrosis had been excluded. For two patients, the results of rectal suction biopsies were initially misleading. Two infants died. Extensive intestinal aganglionosis should be considered a rare possibility in all infants with meconium ileus. In such cases, histological examination of the appendix may avoid this potential pitfall.

Postoperative elective ventilation in babies with "marked anastomotic tension" after repair of esophageal atresia.

The repair of esophageal atresia, preserving the patient's own esophagus is the surgical procedure of choice. In "long-gap" type or in "tension anastomosis" cases, anastomotic complications were known to be higher than in usual cases. From this report, postoperative elective ventilation for 5 days together with neck flexion position reduced such complications with minimal subsequent complications related to the mechanical ventilation.

Aortopexy for tracheomalacia in oesophageal anomalies.

Forty-eight patients with repaired congenital oesophageal anomaly underwent aortopexy for significant tracheomalacia between 1980 and 1990. Indications for aortopexy included recurrent apnoea/cyanosis in 31, near fatal episodes in 16, recurrent respiratory distress and infection in 20 and worsening stridor in 15. Gastro-oesophageal reflux was noted in 30 patients, recurrent fistula in 6 and oesophageal stricture in 14. Aortopexy cured near fatal episodes in all patients and resulted in improvement of airway obstruction in 95%. The procedure failed in 2 patients due to unrecognised bronchomalacia and phrenic nerve palsy respectively. Aortopexy is the primary procedure of choice for significant tracheomalacia when associated with near fatal episodes and significant airway obstruction.

Increased expression of muscular neural cell adhesion molecule in congenital aganglionosis.

BACKGROUND: Neural cell adhesion molecule (NCAM) is down regulated during morphogenesis and innervation of cardiac and skeletal muscle. In mature muscle, its reexpression over the entire sarcolemma occurs in response to denervation or paralysis of muscle and in some myopathies. No information is available regarding NCAM expression in human enteric muscle either in health or in disease. Our aim was to test whether NCAM is present in nerves and muscle of normal infant bowel and to determine how its expression is altered in congenital aganglionosis. METHODS: Using immunocytochemistry for light microscopy, we compared the pattern of distribution of NCAM in congenitally aganglionic colon with that in colon from age-matched controls. RESULTS: In normal colon, NCAM immunoreactivity was seen in ganglion cells and nerve fibers throughout the gut wall and, more weakly, on the inner border of the circular muscle. In aganglionic bowel, there was a marked increase in NCAM expression in muscle, particularly that of the muscularis mucosac and characteristic hypertrophied nerve bundles of the intermuscular zone and submucosa displayed immunoreactivity for NCAM. CONCLUSIONS: Abnormal expression of NCAM is, thus, a feature of congenital aganglionosis and is likely to be associated with neuromuscular dysfunction within the affected colon.

Recurrent necrotizing enterocolitis.

In the decade 1981 to 1991, 16 infants developed recurrent necrotizing enterocolitis (NEC). They comprised 12 (6%) of 196 neonates referred for further management of NEC and four others referred with major congenital anomalies. Their median gestational age was 32 weeks (range, 27 to 40), median birth weight was 1,260 g (range, 790 to 3,230), and the sex distribution was equal. Recurrent NEC occurred after a median interval of 37 days (range, 11 to 163) from the onset of the initial episode. All but one of the 16 infants were either premature (n = 10) or mature with major congenital anomalies (n = 5). Nine patients had previously undergone surgery for NEC. Medical treatment was successful in 11 patients with recurrent NEC. Two infants died, both of liver failure related to parenteral nutrition; one of whom had suffered four separate episodes of NEC and was found to have a superior mesenteric artery occlusion. There was no consistent association between recurrent NEC and the type or timing of enteral feeds or the anatomical site or method of management of the original attack. The mortality of 12.5% was similar to that for primary NEC.

Immunocytochemistry for neuronal markers shows deficiencies in conventional histology in the treatment of Hirschsprung's disease.

Despite technically satisfactory operations, at least 20% of children with Hirschsprung's disease have an unsatisfactory postoperative result. A possible explanation for their symptoms is the retention of ganglionic intestine which has demonstrable abnormalities of the enteric nervous system. The distribution of intestinal neural proteins and peptides in resected colons from patients with Hirschsprung's disease (n = 10) was compared with that in normal controls (n = 5). Immunocytochemistry was performed using antisera against general markers of the enteric nervous system (PGP 9.5, NSE, NFILs, and S-100 protein) and colonic neuropeptides (VIP, GAL, SP, NPY, CGRP, and Met-ENK). The distribution and density of peptide-containing nerve fibers varied greatly from one patient to another and no consistent pattern of neural disturbances could be discerned in aganglionic colon. At the proximal limit of resection, abnormalities of enteric innervation were detected in 8 of 10 studied specimens. Although ganglion cells staining positively for general neuronal markers were present in all cases, normal populations of neural cell bodies immunoreactive for neuropeptides could be found in only 2 specimens. Enlarged submucosal nerve trunks found in the most proximal area of most specimens, displayed immunoreactivity for general nerve markers and VIP, GAL, NPY, and CGRP. The widely practised conventional histopathological assessment of the proximal limit of colonic neural abnormalities may be inadequate.

Problems with intestinal lengthening.

The surgical problems encountered in treating three infants with short-bowel syndrome are reported. The two survivors demonstrate many of the problems associated with the very short-bowel syndrome and both are dependent on parenteral nutrition despite undergoing intestinal lengthening.