The effects of internal thoracic artery preparation with intact pleura on respiratory function and patients' early outcomes.

OBJECTIVE: Postoperative respiratory functions, arterial blood gases, blood loss and clinical outcome following coronary artery bypass surgery (CABG) were assessed in a prospective randomized single-blind (patient- blind) clinical study comparing two different techniques of internal thoracic artery (ITA) harvesting. METHODS: Fifty-four patients admitted for CABG were allocated into two groups according to 'random numbers' technique. In a Group 1 (n=26) ITA was prepared keeping the pleura intact and in a Group 2 (n=28) pleura was opened. Both groups were compared in terms of postoperative respiratory functions, arterial blood gases, bleeding and clinical outcomes using ANOVA for repeated measurements analysis. RESULTS: Analysis of spirometric and partial oxygen pressure data showed that postoperative reductions in forced expiratory volume (0.17+/-0.18 lt vs. 0.28+/-0.14 lt, p=0.016), forced vital capacity (0.18+/-0.19 lt vs. 0.28+/-0.13 lt, p=0.037) and arterial oxygen measurements (-0.03+/-0.22 mmHg vs. 0.15+/-0.4 mmHg, p=0.023) were less pronounced in patients of Group 1 as compared with patients of Group 2. The increase in intrapulmonary shunts (Qs/Qt ratio) after the operation was more pronounced in Group 2 patients than in Group 1 patients (p<0.01) and the mean values of Qs/Qt ratio 24 hours after the operation were higher in group 2 as compared to Group 1 patients(0.100+/-0.063 vs. 0.054+/-0.048, p=0.001). Radiological evaluation revealed that costophrenic angle obliteration after operation more often occurred in Group 2 (14/28 patients) than in Group 1 (0/26 patients) (p<0.0001). Cardiothoracic index increased significantly after operation only in group 2 patients (p=0.001). Postoperative blood loss within 24 hours was significantly lower in Group 1 compared to Group 2 (656+/-179 ml vs. 907+/-257 ml, p=0.001). There was no significant difference between groups in the ICU stay duration (p=0.186), whereas the hospital stay was significantly longer in group 2 patients than in Group 1 patients (8.8+/-2.0 days vs. 7.6+/-2.0 days, p=0.039). CONCLUSION: According to our results, preserving pleural integrity has positive effects on the respiratory functions and patients' clinical outcomes following CABG operations.

Use of the navigator probe after radiotracer injection to identify nonpalpable rib lesions requiring surgical resection.

BACKGROUND: : Patients with nonpalpable rib lesions (NPRL) requiring biopsy present a challenging problem for the thoracic surgeon. Ideally, a small incision directly over the NPRL should be performed to minimize morbidity, particularly if the lesion is benign. The Navigator probe is routinely used after lymphoscintigraphy by surgical oncologists to isolate sentinel lymph nodes requiring removal, but can also be used to guide resection of nonpalpable focal rib lesions demonstrating increased technetium-99m hydroxymethylene diphosphonate (Tc-99m HDP) uptake. This report describes our initial experience with this technique. METHODS: : Over a 5-month period, 3 patients with focal NPRL underwent rib resection. All patients had solitary lesions demonstrated on recently performed Tc-99m HDP bone scanning. Prior cancers were reported in 2 patients, and pain in 2 patients. Before surgery, all patients underwent intravenous injection of 20 to 25 mCi Tc-99m HDP at least 2 hours before the Navigator probe-guided procedure. RESULTS: : The Navigator probe identified all 3 lesions, allowing a single 4 cm or smaller incision in all cases. Histology included metastatic breast cancer (1), pathologic fracture secondary to metastatic palatal cancer (1), and eosinophilic granuloma (1). No patient required further resection. CONCLUSIONS: : Intraoperative localization of NPRL that are positive on Tc-99m HDP bone scanning using the Navigator probe is feasible and was 100% successful in our initial experience. This technique allows a minimally invasive approach, which is beneficial for those patients who do not require further resection.

Arch-first technique via clamshell incision: successful surgical reoperation for aortic arch dissection.

We report a case of successful reoperation for aortic arch dissection with use of the "arch-first" technique in a patient who had Marfan syndrome. Extracorporeal circulation was initiated via right subclavian artery cannulation, and the chest was entered through a clamshell incision for the best exposure. When the patient was cooled to 18 degrees C, the perfusion was stopped. After the 1st aortic arch anastomosis to a 30-mm Dacron graft, cerebral perfusion was reestablished via the right subclavian artery. The aortic repair was then completed. The cerebral ischemic time was 18 minutes, the aortic cross-clamp time was 69 minutes, and the total extracorporeal circulation time was 334 minutes. The patient was discharged from the hospital on postoperative day 10 with no neurologic impairment. The arch-first technique shortens the duration of brain ischemia. When combined with a clamshell incision, the technique is particularly helpful for reoperation of the aortic arch and thoracic aorta.

Aortic arch reconstruction with pulmonary autograft patch in coarctation and interruption of the aorta.

The surgical management of the aortic arch pathologies is still subject to discussion. Primary end-to-end anastomosis has some complications such as bronchial compression, tension in the suture lines, and probability of recurrence. On the other hand, patch aortoplasties combined with end-to-end anastomosis carry the risk of aneurysm formation and recurrence. Considering the growth potential, pulmonary autograft patch use in aortic arch reconstructions has recently been introduced into clinical practice. In this study, we present the early findings of combined end-to-end anastomosis and pulmonary autograft patchplasty procedure in six patients. According to our experience the technique applied in this report seems to be more advantageous than other conventional approaches.