Progression to 100% off-pump coronary artery bypass with the Octopus 1 dual holder.

BACKGROUND: Can off-pump coronary artery bypass grafting become the routine standard in all elective primary coronary artery bypass grafting (CABG) operations? This paper shows how this aim has been achieved during one year in 130 off-pump cases performed through a sternotomy. This strategy allows for full revascularization (up to six grafts) without the disadvantage of cardiopulmonary bypass. The study introduces a variant of the Octopus stabilizer, a single Octopus 1 arm (Medtronic, Inc., Minneapolis, MN) with a dual holder. MATERIALS AND METHODS: From November 1998 through February 2000, 130 patients underwent coronary artery bypass grafting through a sternotomy off-pump utilizing a stabilizer and CO2 blower. The stabilizer most frequently used to achieve this was a single Octopus 1 arm equipped with a dual holder to accommodate two straight suction pods. The holder allowed increased flexibility and manipulation of the suction pods with an equivalent of seven degrees' freedom of motion at the dual holder junction. Techniques for carrying out total revascularization are discussed. The progress of proportion of elective primary CABG revascularization performed off-pump is shown and results are compared with published reviews of the literature for off-pump coronary revascularization. RESULTS: Patient demographics included: age range 32 to 87, mean 61.3; female sex: 17%; ejection fraction < 50%: 54%; presence of left main stem disease: 17%. Overall Parsonnet risk score ranged 0-31, with a mean of 8.8. Graft numbers carried out were: 34 x 2, 34 x 3, 32 x 4, 25 x 5 and 5 x 6 anastomoses respectively. The mean number of distal anastomoses was 3.6 +/- 1.0. There was extensive coverage of the lateral aspect of the heart (153 circumflex territory grafts, 33%). Radial artery, left internal mammary artery or saphenous vein sequential (jump) grafts were used in 26 cases (20%). Apart from general experience, the use of the dual holder and wide opening of the right pleura were the two important factors allowing freedom for multi-vessel lateral and posterior wall grafting. Thirteen Genzyme (Genzyme Surgical Products, Inc., Cambridge, MA) and ten Octopus 2 (or 2+) stabilizers were used, mostly for two or three grafts. The remainder were carried out using the Octopus 1 (dual holder: 83). In the first three-month period, 31% of cases were off-pump compared to the last three-month period, when 96% were off-pump. In the last two months we performed 100% of all 27 cases referred off-pump. There were no deaths, strokes or myocardial infarctions. Ventricular arrhythmia occurred in two cases. Conversions to bypass were undertaken twice. Two unexpected renal failures occurred, neither of which were from the 13 patients with preoperative incipient renal failure, of whom none suffered a rise in postoperative creatinine of greater than 30%. The results compare favorably with published results despite having a large mean number of grafts of 3.6. CONCLUSION: Off-pump surgery with full revascularization has now become feasible for all primary elective coronary artery graft operations.

The influence of vascular pressure and different primes on the fluid balance of, and oxygen supply to, the patient during CABG.

Detrimental changes of blood and erythrocyte rheology, and fluid exchange between the vascular and interstitial spaces, which influence the rate that oxygen is supplied to the patient, occur during cardiac bypass surgery. Venous flow is subject to a pulsatile and uncertain variation, because the vena cava is more than 30 mmHg below atmospheric pressure. This occurs because the patient is about 1 m above the air-blood surface of the bypass reservoir. Before any reliable study of fluid exchange can be undertaken this effect must be controlled. It was then established that optimum oxygen exchange occurs when equilibration of the plasma oncotic pressure and the capillary hydrostatic pressure is achieved without alteration of the interstitial fluid volume. At the lower arterial blood pressures used during bypass, it is necessary to reduce the plasma oncotic pressure by using an appropriate volume of crystalloid prime.

Management of hypopharyngeal carcinoma: a 6-year review.

A retrospective review of 16 consecutive cases of squamous carcinoma of the hypopharynx treated by pharyngo-laryngo-oesophagectomy (PLO) and gastric transposition with a thoracotomy as part of the surgical technique is presented. An operative mortality of 6% and a hospital mortality of 12% occurred. Other complications are discussed. No significant morbidity or mortality occurred as a result of the thoracotomy. A comparison is made with the extra-thoracic technique of gastric transposition.