Myonecrosis secondary to Clostridium Septicum in a patient with Occult Colon Malignancy: a case report

© 2008 Gibson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Surgical Outcomes in Syndromic Tetralogy of Fallot: A Systematic Review and Evidence Quality Assessment

Tetralogy of Fallot (ToF) is one of the most common cyanotic congenital heart defects. We sought to summarize all available data regarding the epidemiology and perioperative outcomes of syndromic ToF patients. A PRISMA-compliant systematic literature review of PubMed and Cochrane Library was performed. Twelve original studies were included. The incidence of syndromic ToF was 15.3% (n = 549/3597). The most prevalent genetic syndromes were 22q11.2 deletion (47.8%; 95% CI 43.4–52.2) and trisomy 21 (41.9%; 95% CI 37.7–46.3). Complete surgical repair was performed in 75.2% of the patients (n = 161/214; 95% CI 69.0–80.1) and staged repair in 24.8% (n = 53/214; 95 CI 19.4–30.9). Relief of RVOT obstruction was performed with transannular patch in 64.7% (n = 79/122; 95% CI 55.9–72.7) of the patients, pulmonary valve-sparing technique in 17.2% (n = 21/122; 95% CI 11.5–24.9), and RV-PA conduit in 18.0% (n = 22/122; 95% CI 12.1–25.9). Pleural effusions were the most common postoperative complications (n = 28/549; 5.1%; 95% CI 3.5–7.3). Reoperations were performed in 4.4% (n = 24/549; 95% CI 2.9–6.4) of the patients. All-cause mortality rate was 9.8% (n = 51/521; 95% CI 7.5–12.7). Genetic syndromes are seen in approximately 15% of ToF patients. Long-term survival exceeds 90%, suggesting that surgical management should be dictated by anatomy regardless of genetics

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Developing New Surgical Skills and Techniques as a Young Cardiothoracic Surgeon

<p>After finishing seven or eight years of general and cardiothoracic surgery training, the young cardiac or thoracic surgeon often faces the challenge of tailoring their practice to the new era. One of my mentors used to say that today he uses only about 25 to 30 percent of the techniques and skills that he learned during his training. This means that he had to develop new skills in order to be in line with new technologic advancements and surgical methods. Ten years ago, many portions of our everyday practice were not common or did not even exist: transcutaneous valves, robotic surgery, MitraClip™, thoracoscopic ablation for atrial fibrillation, hybrid aortic surgery, totally implantable ventricular assist devices, and thoracic endovascular aortic repair. However, only a few training programs give adequate exposure to residents in all of these fields.</p><p>So the question is: how do I acquire new skills and techniques that I never learned during my training, while building and maintaining a busy practice?</p><p>In my opinion, the fundamental goal of a solid training program in cardiothoracic surgery is to teach traditional surgery, which is usually maximally invasive (with video-assisted thoracoscopic surgery being a good exception). The cardiothoracic resident must first and foremost learn and master coronary surgery, “maximally-invasive” valve and aortic surgery, and lung and esophageal surgery. They must be primarily exposed to the complexity of traditional cardiac and thoracic surgery before they move on to more advanced skills. After the completion of our formal training, we embark on our surgical career with an early goal to be a successful and safe independent surgeon.</p><p>One can acquire new techniques and skills through the following ways:</p><ol><li>Take some time off from your busy schedule and dedicate a few months, or even a year if possible, to formal training in a new field, such as aortic, transplant, congenital, transcatheter valve replacement, mitral valve repair, robotics, etc. This will give you the opportunity to acquire concentrated knowledge and experience in that new field.</li><li>Attend conferences and courses sponsored by surgical societies or industry. At these events, you will hear from experts in the field about the new techniques and can learn from the successes and complications they have experienced.</li><li>Visit a surgeon or center that performs the technique frequently. Personally, I have found this paradigm very helpful, since you can see someone else operating first-hand and in the real world. Take notes, ask questions, and develop a lifelong professional relationship.</li></ol><p>Once you have done enough training, read thoroughly and prepare for the operation. Create a list of what may go wrong and how to get out of an unpleasant situation. Have a proctor or a mentor scrub with you for your first few cases. You definitely do not want to be the first and only surgeon to do a new technique without any backup. Invite a senior colleague from your institution to be present. Experienced surgeons may not know the new technique that you are trying to implement, but they can give you valuable advice and help with a possible complication.</p><p>Acquiring new skills can be a stressful and upsetting venture. However, it is the best way to make ourselves marketable and keep up with the advancements in our specialty. Cardiac and thoracic surgery are continuously evolving, and we have to adapt to the new technological environment if we wish to remain competitive.</p><p></p

Preoperative percutaneous coronary intervention in patients undergoing open thoracoabdominal and descending thoracic aneurysm repair

ObjectiveCurrent guidelines have recommended against coronary revascularization before noncardiac surgery in patients with asymptomatic coronary artery disease. However, myocardial infarction after thoracic aneurysm (TA) repair dramatically increases the morbidity and mortality. Revascularization with coronary artery bypass grafting before TA repair minimizes the incidence of perioperative ischemia. However, the recovery can be prolonged, and a percentage of patients will either never return for aneurysm repair or will develop a rupture during convalescence. Percutaneous coronary intervention (PCI) before TA repair might be preferable. Previous studies examining PCI before major vascular surgery included few patients with TAs. We examined the outcomes of patients undergoing PCI before TA repair.MethodsFrom 1997 to 2012, 592 patients underwent TA repair. Patients presenting for elective repair underwent cardiac catheterization before surgery. Those with significant single- or double-vessel coronary artery disease underwent PCI. The perioperative outcomes were examined and compared with those of patients undergoing TA repair without revascularization.ResultsA total of 44 patients (7.4%) underwent PCI with bare metal stents before surgery. No PCI-related complications occurred. Dual antiplatelet therapy was administered for 4 to 6 weeks. No instances of aneurysm rupture occurred in the interval between PCI and surgery. The incidence of stent thrombosis, myocardial infarction, and mortality for those undergoing PCI was 0. No bleeding complications occurred.ConclusionsPCI is safe and efficacious in patients undergoing TA repair. Aneurysm rupture did not occur in the interval before surgery. Antiplatelet therapy did not increase the risk of bleeding complications. Stent thrombosis was not seen. We recommend PCI those with significant single- or double-vessel coronary artery disease before elective TA repair

Regional Variation in Arterial Saturation and Oxygen Delivery during Venoarterial Extracorporeal Membrane Oxygenation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be lifesaving in patients with cardiopulmonary collapse. However, observation studies have implied that oxygenated blood does not pass in a retrograde fashion from the VA-ECMO circuit to the aortic root and arch when the femoral artery (FA) is used. This study aims at accurately measuring the oxygen saturation in various arteries during VA-ECMO through different cannula sites. A total of 20 patients with VA-ECMO were in the study. Fourteen patients had FA cannulation, two patients received axillary arterial (AA) cannulation, and four patients received cannulation of the ascending aorta. Oxygen saturation was measured simultaneously in the radial artery and oxygenator outlet. In the patient group with FA cannulation, the oxygen saturation was lower in the radial artery (97%) when compared with the oxygenator outlet (>99%). In the subset group of patients with severe lung dysfunction, oxygen saturation was even lower in the radial artery (73% saturation). In the patient group with AA cannulation, the oxygen saturation and partial oxygen pressure (PO2) in the oxygenator outlet and radial artery were similar (99% or greater). In the patient group with direct ascending aorta cannulation, the oxygen saturation and PO2 in the oxygenator outlet and radial artery were similar as well. Regional variations occur in the blood oxygen saturation depending on the site of the arterial cannulation in patients with VA-ECMO. With FA cannulation, the oxygen saturation in the radial artery is significantly lower than the one in the oxygenator outlet. This may imply that the coronaries and the brain receive hypoxic blood from the left ventricle. These results suggest that antegrade cannulation for VA-ECMO improves oxygen delivery to the proximal aorta distribution

A Novel Method for Percutaneous Insertion of a Right Ventricular Assist Device

Right heart failure is a rare but often fatal complication both in the pre- and postoperative setting. Right heart support with a ventricular assist device inserted in the operating room through median sternotomy can be a time-consuming procedure that requires a reoperation for removal. In cases of urgent need of right heart support, a percutaneous technique option may be of benefit. We present our initial experience with a percutaneously inserted right ventricular assist device (RVAD) in an elderly patient with severe right heart failure. An 81-year-old female patient underwent combined aortic and mitral valve replacement at our institution. During the first postoperative evening, the patient sustained sudden cardiovascular collapse and a bedside transesophageal echocardiogram revealed severe right heart failure. A coronary angiogram showed thrombosis of the right coronary artery, which was cleared with a suction device. As a result of the patient’s critical condition, it was decided that an RVAD was needed as a bridge to recovery. The patient’s condition improved significantly almost immediately. Her right heart function recovered over the next few days and the RVAD was removed at the bedside. She made a complete recovery and was discharged home. This patient is a prime example that a totally RVAD can be inserted in urgent situations easily and safely under fluoroscopic and echocardiographic guidance. More clinical experience with percutaneous RVADs is required to establish this technique as an alternative equivalent to the traditional open method. Right heart failure complicates many heart diseases both in the pre- and the postoperative setting. In cases of urgent need of right heart support, a percutaneous technique of a RVAD is needed for a successful outcome. We present our initial experience with a percutaneously inserted RVAD in an elderly patient with severe postoperative right heart failure