Tabula viva chirurgic: a living surgical document.

AIM: The purpose of this article is to present the results of a private cardiac surgical practice. This information could also serve as a hermeneutical text for new wisdom. METHODS: A personal database of 1 750 consecutive patients who had had coronary artery bypass graft (CABG) surgery was statistically analysed. Mortality and major morbidity figures were compared with large registries. Risk factors for postoperative death were determined. RESULTS: Over a period of 12 years, 1 344 (76.8%) males and 406 (23.2%) females were operated on. The observed mortality rate was 3.03% and the expected mortality rate (EuroSCORE) was 3.87%. After stepwise logistic regression, independent risk factors for death were urgency (intra-aortic balloon pump), renal impairment (chronic kidney disease, stage III), re-operation and an additional procedure. Apart from the 53 deaths, another 91 patients had major complications. CONCLUSION: Mortality and morbidity rates compared favourably with other international registries. Mortality was related to co-morbidities. This outcome contributes to a hermeneutical understanding focusing on new spiritual wisdom and meaning for the surgeon.

The effect of the metabolic syndrome on the risk and outcome of coronary artery bypass graft surgery.

BACKGROUND: The individual components of the metabolic syndrome are risk factors for coronary artery disease. The underlying pathophysiology of a low-grade inflammatory process postulates that the metabolic syndrome could compromise a procedure such as coronary artery bypass graft surgery (CABG) done on cardiopulmonary bypass (CPB). METHODS: From a single institution, 370 patients with the metabolic syndrome (IDF and ATP III criteria) and 503 patients without the metabolic syndrome were identified. The influence of the metabolic syndrome on the pre-operative core risk factors for CABG mortality as well as its effect on the mortality and major morbidity post surgery were investigated. RESULTS: Patients with the metabolic syndrome were operated on less urgently than those without the metabolic syndrome. The EuroSCORE was also lower in those with the metabolic syndrome. Patients with the metabolic syndrome required fewer units of homologous red blood cells, but stayed statistically longer in hospital. CONCLUSIONS: In this surgical population the metabolic syndrome had no detrimental clinical effect on either the pre-operative risk factors or the outcome after CABG.

Should I change to OPCAB?

Much is written about the benefits of off-pump coronary artery bypass surgery (OPCAB). Is it applicable to all practices? Does that mean we all need to change to OPCAB? The surgical literature appears to have flaws with regard to providing answers. In striving for evidence-based medicine, one could integrate clinical data with external best evidence or do proper power calculations to determine study sizes. In a local, retrospective, observational study, 535 patients had a CABG done with the aid of cardiopulmonary bypass and cardiac arrest. Five hundred and seven patients were considered appropriate for analysis. Mortality was seven (1.4%), the prevalence of myocardial infarction four (0.8%), renal dialysis was four (0.8%) and stroke six (1.2%). Eighty (16%) patients required homologous blood transfusions. The median length of hospital stay was five days. If a local, randomised, controlled study was to be conducted to confirm an improvement with OPCAB, a large number of patients would be needed. For a 12.5% reduction in an event rate presently at 0.8%, 262,000 patients would be necessary. For a 50% reduction in an event rate presently at .0%, 2300 patients should be recruited. The local prevalence rate is very low and the number of patients required for a series is too high. The supremacy of OPCAB for this practice is therefore not established.

Profile and outcome of patients referred for thoracic empyema in Bloemfontein, South Africa.

OBJECTIVE: To establish the profile and outcome of patients referred to the Department of Cardiothoracic Surgery at Pelonomi Hospital, Bloemfontein for management of thoracic empyema. This was considered important in view of the proposed restructuring of health services in the Free State. METHODS: Files of 77 consecutive patients referred to the Department of Cardiothoracic Surgery at Pelonomi Hospital were reviewed. The effect of condition of the ipsilateral lung on the outcome was statistically analysed. This series was compared with a similar size series from Crawford Hospital in Atlanta, Georgia, USA. RESULTS: The male-to-female ratio was 6:1. Eighty-three per cent of patients were referred from a hospital. The aetiology included a wide variety of causes, but trauma (56%), destroyed lung (10%) and pneumonia (9%) were the most common causes. Active tuberculosis was diagnosed in 6 patients, and the prevalence of HIV was 16%. Mismanagement had probably occurred in 21 cases (27%), usually involving an intercostal drain left in for too long. Surgery was eventually necessary in 52 cases (68%). The final outcome was good in 64 of the 77 patients (83%). CONCLUSIONS: The high prevalence of surgery requires timely referral to a specialised cardiothoracic surgeon, and facilities should be available. Empyema associated with a diseased lung, especially a destroyed lung, is a therapeutic challenge and the outcome is often unsatisfactory.