Cephalic pancreaticoduodenectomy with preservation of a right coronary artery bypass graft using the right gastro-epiploic artery: a case report.

INTRODUCTION: Pancreatic cancer is a rare disease with a high mortality rate, for which complete surgical resection, when possible, is the preferred therapeutic. Pancreaticoduodenectomy represents the surgical technique of choice. Abdominal surgeons can be faced with the challenge of patients with a history of coronary artery bypass graft in which the right gastro-epiploic artery is used. CASE REPORT: We report the case of a patient with an adenocarcinoma of the pancreatic head, stage IIA, having previously undergone a triple coronary artery bypass, one of which being a right gastro-epiploic graft. Our challenge was underlined by the necessity of a complete oncological resection through a cephalic pancreaticoduodenectomy while preserving the necessary cardiac perfusion via the right gastro-epiploic artery. CONCLUSION: We have been able to preserve a right gastro-epiploic artery as a coronary bypass during a cephalic pancreaticoduodenectomy for a cephalic pancreatic adenocarcinoma. We have successfully been able to preserve and re-implant the right gastro-epiploic artery to the origin of the gastroduodenal artery while insuring R0 resection of the tumor. A coronary artery bypass using the right gastro-epiploic artery should therefore not be considered as an obstacle to a Whipple's procedure if total oncological resection is obtainable.

Immediate and day-to-day reproducibility of the signal-averaged electrocardiogram in patients with coronary artery disease.

The purpose of this study was to prospectively evaluate the immediate (5 minutes) and short-term (1 day) reproducibility of the signal-averaged electrocardiogram (SAECG) in patients with coronary artery disease. A total of 59 consecutive patients with coronary artery disease (50 male, 9 female, mean age 59 +/- 13 years) were included. Analysis was performed using a commercially available system with high-pass filters of 25, 40, and 80 Hz without any change in electrode position. The following time-domain parameters were measured: (1) total filtered QRS duration; (2) duration of high-frequency low-amplitude signals (HFLA); and (3) root-mean-square voltage of the terminal 40 ms of the QRS complex (RMS40). Correlation between pairs of measurements was excellent, ranging from 0.91-0.99 for QRS and HFLA duration, and from 0.83-0.98 for RMS40 value. However, the range of differences was wide for all parameters, especially at 25 and 80 Hz, revealing marked individual variations in selected cases. The immediate reproducibility of an initially normal SAECG was 95% at 25 Hz, 100% at 40 Hz, and 81% at 80 Hz; figures for an initially abnormal SAECG were 89%, 91%, and 93%, respectively, and the coefficient of agreement kappa was highest at 40 Hz than at 25 or 80 Hz. Discordant results were most frequently observed in patients with borderline values, or in cases with nonsimilar residual noise levels. In conclusion, the immediate and day-to-day reproducibility of the SAECG is excellent in patients with chronic stable coronary artery disease. However, individual variations are observed in selected cases, leading to modification in interpretation of the result. For this reason, individual reproducibility should be considered before evaluating the effect of any therapeutic intervention on the SAECG, especially in patients with borderline values of the quantitative parameters of the SAECG.

Coronary artery bypass grafting with the inferior epigastric artery. Midterm clinical and angiographic results.

Between December 1988 and September 1993, 157 patients (141 men, 16 women, average age 60.2 years, range 37 to 78 years) underwent a complete myocardial revascularization with 157 inferior epigastric artery grafts and 285 internal mammary artery grafts (281 in situ, 4 free grafts). A total of 543 distal arterial anastomoses (average 3.4, range two to five per patient) were constructed, 376 with the internal mammary artery and 167 with the inferior epigastric artery. The inferior epigastric artery grafts were anastomosed to two left anterior descending, 5 diagonal, 34 circumflex, and 126 right coronary arteries. The indications for the use of the inferior epigastric artery were the unavailability of conventional conduits in 56 patients and a favorable anatomy or a young age in 101 selected patients. The clinical follow-up averages 31.8 months (range 6 to 62 months). Four patients died early, and there were three perioperative nonfatal myocardial infarctions. Eight patients required early reoperation for thoracic bleeding (2) or drainage of an abdominal parietal collection (6). There were four late deaths (2 sudden deaths, 2 noncardiac causes) and one nonfatal myocardial infarction. Angina recurred in nine patients, of whom one required reoperation and three underwent successful percutaneous balloon angioplasty of a native coronary artery (2) or an old saphenous vein graft (1). An early recatheterization was obtained before discharge (average 11 days) in 135 patients: 132 of 135 inferior epigastric artery grafts were patent. Seventy-seven patients underwent a second angiographic restudy 6 to 43 months after the operation. Forty-four of the 48 inferior epigastric artery grafts restudied within the first postoperative year (average 8.5 months) were patent, but eight showed a diffuse narrowing. Twenty-eight of the 29 inferior epigastric artery grafts examined angiographically between 13 and 43 months (average 25 months) were open, and among those 29, 25 were widely patent, perfectly matching the receiving coronary artery. Most of the occluded or narrowed inferior epigastric artery grafts were grafted onto coronary arteries with mild stenosis at restudy. Five patients underwent a third angiographic reexamination up to 60 months after the operation (average 39 months). All five inferior epigastric artery grafts were widely patent. The early attrition rate of the inferior epigastric artery, as for any free arterial graft, is probably the result of both the loss of a true pedicle and the need for constructing an additional proximal anastomosis. The fact that the patency rate of the inferior epigastric artery graft seems to remain stable beyond 1 year could suggest a good durability in the future.

Quantitative angiographic follow-up study of the free inferior epigastric coronary bypass graft.

BACKGROUND: Attempts to improve late results of bypass coronary surgery have focused on the use of arterial conduits because of the high attrition rate of venous grafts. METHODS AND RESULTS: In our institution, 150 patients received an inferior epigastric artery (EPIG) as a free bypass graft, anastomosed to the right coronary artery in 73% and to a marginal branch in 20% of cases. These patients were followed prospectively by qualitative and quantitative angiography. Angiographic studies were performed in 122 patients (81%) early after surgery (11 +/- 5 days), and in 72 cases, a late evaluation (11 +/- 6 months) was also obtained. Quantative angiography (basal and after isosorbide dinitrate [ISDN]) was performed on the in situ EPIG in a large subset of these patients, as well as in 59 patients before bypass surgery. The patency rate was 98% at early control and remained high (93%) at late control. However, at late control, 14 EPIGs were occluded or threadlike, but of these 14, eight were grafted on a coronary artery with a moderate stenosis (< or = 60%) and with good anterograde perfusion. Mean basal EPIG diameter increased from 2.23 +/- 0.42 mm before surgery to 2.57 +/- 0.52 mm at 11 days (P < .01) but decreased to 2.20 +/- 0.47 mm in late study (P < .01 versus 11 days and P = NS versus before surgery). Vasodilation of EPIG with ISDN was observed before surgery (+0.34 +/- 0.20 mm, P < .001) and at late control (+0.20 +/- 0.17 mm, P < .001) but not in the early postoperative period for the whole group. Early after surgery, basal diameter was not different from native EPIG dimensions after ISDN (2.57 +/- 0.52 versus 2.56 +/- 0.39 mm), suggesting maximal dilation. However, vasodilation with ISDN was observed in a subgroup of patients at this time. These responder patients (n = 51) had a smaller basal diameter (2.47 +/- 0.49 versus 2.67 +/- 0.54 mm, P < .05) and a smaller runoff (P < .001) than nonresponder patients. CONCLUSIONS: EPIG grafts have a good early patency rate. The mid-term patency rate remains high and seems to depend, at least partially, on flow through the native coronary artery. EPIGs initially increase their lumen size, probably to meet the increased blood flow due to myocardial requirements. Over time, EPIG diameters decrease mainly as a result of a higher basal vasomotor tone. Long-term angiographic follow-up (eg, 5 to 10 years) is needed to assess late patency rate and the relation with these early findings and will define the place of this new coronary bypass conduit.