Minimally invasive aortic valve replacement surgery through lower half sternotomy.

Less invasive approaches to aortic valve surgery frequently rely upon the development of new technology and instrumentation. While not suitable for every patient requiring an aortic valve procedure, these less invasive operations can offer certain clinical benefits and are becoming an important part of the modern cardiothoracic surgeon's skillset. A lower partial sternotomy approach provides excellent visualization of the operative field, efficient execution of the operation and many of the benefits of minimally invasive surgery. Importantly, the lower partial sternotomy requires no new or unusual instruments and presents a familiar view to the surgeon. The technique, therefore, lends itself well to being adapted and utilized quickly with a potentially shorter "learning curve" for maximal surgical flexibility and patient benefit.

Feeding jejunostomy tubes placed during esophagectomy: are they necessary?

BACKGROUND: Jejunostomy tubes (JT) are routinely placed at the time of esophagectomy and can be associated with low--but not insignificant--morbidity. Increased emphasis on evidence-based medicine prompted this critical review of JT use during esophagectomy and factors that predict the absolute need for JT. METHODS: All esophagectomies performed at one tertiary care institution from 1995 through 2009 were retrospectively reviewed. Statistical analyses were performed to determine preoperative variables that would assist in selecting patients who should receive a JT. RESULTS: A total of 143 JTs were placed in 151 patients undergoing esophagectomy for carcinoma (83.4%), high-grade dysplasia (13.2%), and perforation (2.6%). Of these, 110 patients (76.9%) had returned to oral intake before discharge (median, 7 days), whereas 33 patients (23.1%) still required tube feedings. Of 8 patients who did not undergo intraoperative JT placement, 6 had resumed oral intake at discharge. Two patients were discharged on total parenteral nutrition. Logistic regression analysis of preoperative variables showed a body mass index of less than 18.5 kg/m2 conferred a likelihood of requiring a JT at discharge (odds ratio, 7.56; p<0.05). Age, sex, albumin level, type of esophagectomy, histology, stage, preoperative neoadjuvant therapy, and type of cancer were not significant predictors of JT need at discharge. CONCLUSIONS: The only absolute indication for JT placement after esophagectomy was a body mass index of less than 18.5 kg/m2. Other patients may have selective JT placement based on the surgeon's judgment.

Novel repair of venous aneurysms secondary to arteriovenous dialysis fistulae.

This report describes the surgical management of 12 hemodialysis patients with arteriovenous fistulae in whom non-infected, fusiform venous aneurysms developed that compromised access for dialysis. The venous aneurysmal changes were too extensive to permit excision and primary veno-venous anastomosis. To avoid the use of synthetic interpositional grafts, the venous aneurysms were left in situ and reduced in size to match the diameters of the veins entering and exiting the aneurysms. After decompression, the lumens of the venous aneurysms were reduced by firing staple lines along the longitudinal axes of the venous aneurysms and excision of the aneurysmal tissue anterior to the staple lines. Twenty-eight aneurysms were repaired by this method of reduction aneurysmoplasty, in 15 operations on 12 patients over the past 10 years. There were no wound infections or dehiscences and no bleeding or hematomas. After the operations, the arteriovenous fistulae were used continuously for hemodialysis until the patients died (7 patients for 36 months -/+ 28 SD), were lost to follow-up (1 patient at 30 days postoperatively), until the arteriovenous fistulae thrombosed following revision of the arteriovenous anastomosis (1 patient at 41 months postoperatively), or until the arteriovenous fistulae was ligated to relieve pain in the upper arm (1 patient at 6 months postoperatively). Two patients continue to use their arteriovenous fistulae until and including the time of this report at 10 and 11 months, respectively. Reduction aneurysmoplasty as described in this report offers an effective and low-risk option for the management of venous aneurysms secondary to arteriovenous fistulae in hemodialysis patients.