Minimally Invasive Bilateral Lung Resections and CABG through 5 Ports.

Minimal access surgery is increasingly popular to reduce postoperative morbidity and enhance recovery. We present a case of a patient who underwent bilateral minimally invasive thoracic and cardiac surgery. An 81-year-old woman was diagnosed with T1aN0M0 left upper lobe small-cell lung cancer and underwent single-port left video-assisted thoracoscopic surgery (VATS) upper lobectomy in 2016. She developed a contralateral right lower lobe nodule and underwent a single-port right VATS wedge resection of the lower lobe nodule, subsequently confirmed as necrotising granulomatous inflammation with acid-fast bacilli, consistent with previous tuberculosis (TB) infection. On postoperative day 1, she had an episode of self-reverting ventricular tachycardia and bradycardia. Subsequent myocardial perfusion scan and coronary angiogram showed significant LV dysfunction and severe coronary artery disease with a left main stem (LMS) lesion. After agreement at MDT, an Endo-ACAB (endoscopic atraumatic coronary artery bypass grafting) was performed, via 3 ports, with the left internal mammary artery anastomosed to left anterior descending artery. She recovered well postoperatively and was discharged. Multiple sequential minimally invasive procedures are now routine and can be performed safely in patients with a complex combination of pathologies. In this case, bilateral single-port (anatomic and nonanatomic) lung resections were undertaken followed by coronary revascularisation with a total of 5 minimal access ports.

Off-pump versus on-pump revascularization in females: a meta-analysis of observational studies.

BACKGROUND: Coronary revascularization in female patients presents several challenges, including smaller target vessels and smaller conduits. Furthermore, late presentation and more co-morbidities than males may increase complication rates. The aim of this study was to assess whether off-pump coronary artery bypass (OPCAB) improves outcomes when compared to on-pump coronary artery bypass (ONCAB) in the female population. METHODS: A systematic literature review identified six observational studies, incorporating 23313 patients (n=9596 OPCAB, 13717 ONCAB). These were meta-analyzed using random effects modeling. Heterogeneity, subgroup analysis, quality scoring and publication bias were assessed. The primary endpoints were 30-day mortality and major cardiac, respiratory and renal complications. Secondary endpoints were the number of grafts per patient. RESULTS: No statistically significant difference was observed in 30-day mortality between the OPCAB and ONCAB groups (4.8% vs. 0.7%; OR 0.96; 95% CI [0.41, 2.24], p=0.92). Significant inter-study heterogeneity was also present (I2=94%) and was not explained by study size or quality. Peri-operative myocardial infarction (OR 0.65; 95% CI [0.51, 0.84], p=0.0009) was significantly lower with OPCAB without significant heterogeneity; however, OPCAB did not significantly alter other morbidity outcomes. OPCAB was associated with a trend towards fewer grafts per patient than ONCAB. CONCLUSIONS: OPCAB is a safe alternative to ONCAB in the surgical revascularisation of female patients and may reduce post-operative myocardial infarction (MI). However, this does not translate into a reduction in 30-day mortality and OPCAB does not significantly improve other cardiovascular, renal or neurological outcomes. Late outcome data remains lacking and a well-structured, randomized trial is required to answer vital questions regarding the effect of OPCAB on women in the long-term.

Does off-pump coronary revascularization reduce mortality in re-operative coronary artery surgery? A meta-analysis of observational studies.

BACKGROUND: Re-operative coronary artery bypass grafting (CABG) is a challenging operation that is often performed in a high-risk patient group. Avoiding cardiopulmonary bypass (CPB) in these patients is hypothesised to be advantageous due to the reduced invasiveness and physiological stress of off-pump coronary artery bypass grafting (OPCAB). The aims of this study were to assess whether OPCAB may improve outcomes in patients undergoing re-operative CABG. METHODS: Twelve studies, incorporating 3471 patients, were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were 30-day and mid-term mortality. Secondary endpoints were completeness of revascularization, mean number of grafts per patient and the effect of intra-operative conversion on mortality. RESULTS: A significantly lower rate of 30-day mortality was observed with OPCAB (OR 0.51, 95% CI [0.35, 0.74]), however, no difference was demonstrated in mid-term mortality. Significantly less complete revascularization and mean number of grafts per patient were observed in the OPCAB group. Meta-regression revealed no change in 30-day mortality when the effect of conversion from one technique to the other was assessed. CONCLUSIONS: Off-pump techniques may reduce early mortality in selected patients undergoing re-operative CABG; however, this does not persist into mid-term follow-up. OPCAB may also lead to intra-operative conversion and, although this did not affect outcomes in this study, these results are constrained by the limited data available. Furthermore, OPCAB may increase target vessel revascularization and, consequently, incomplete revascularization which, whilst not reflected in the short-term outcomes, requires longer-term follow-up in order to be fully assessed.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis.

OBJECTIVE: Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system. METHODS: Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used. RESULTS: Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes. CONCLUSION: This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

Miniaturized extracorporeal circulation vs. off-pump coronary artery bypass grafting: what the evidence shows?

Recognition of the potentially deleterious effects of esxtracorporeal circulation led to off-pump coronary artery surgery (OPCAB) experiencing a surge in popularity in the initial decade after its conception. However, OPCAB has its own limitations and technical difficulties, such as coronary access, increased left ventricular size and reduced function, which may lead to the potential for suboptimal revascularization. As an alternative technique, miniaturized extracorporeal circulation (mECC) may provide a more controlled operative field in which the heart may be manipulated whilst minimizing the inflammatory, coagulopathic and haemodilutional effects of cardiopulmonary bypass. In this review, we outline the proposed benefits of the mECC system, discuss the pitfalls associated with mECC, and directly compare mECC to 'off-pump' coronary surgery for a variety of clinical and non-clinical outcomes.