The American Association for Thoracic Surgery Consensus Guidelines: Reasons and purpose Svensson, Lars G., MD, PhD; Gillinov, A. Marc, MD; Weisel, Richard D., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
04/2016, Letnik:
151, Številka:
4
Journal Article
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Abstract The time interval for the doubling of medical knowledge continues to decline. Physicians, patients, administrators, government officials, and payors are struggling to keep up to date with ...the waves of new information and to integrate the knowledge into new patient treatment protocols, processes, and metrics. Guidelines, Consensus Guidelines, and Consensus Statements, moderated by seasoned content experts, offer one method to rapidly distribute new information in a timely manner and also guide minimal standards of treatment of clinical care pathways as they are developed as part of bundled care programs. These proposed Consensus Guidelines advance The American Association for Thoracic Surgery's mission of leading in cardiothoracic health care, education, innovation, and modeling excellence.
We sought to evaluate the potential benefits of minimally invasive approaches for treatment of isolated aortic and mitral valve disease.
From 7/96 to 04/03, we performed 1000 minimally invasive valve ...operations: 526 aortic (AV) procedures (64 years; mean, 25-95) and 474 mitral (MV) procedures (58 years; mean, 17-90).
In the AV group, an upper ministernotomy was used in 492/526 patients (93%) and a right parasternal approach in 34 (7%). Sixty-three patients had reoperative aortic valve replacements. In the MV group lower sternotomy was used in 260/474 (55%), right parasternal in 200/474 (42%), and a right thoracotomy in 14 patients. MV repair was performed in 416 and MV replacement in 58 patients. Operative mortality was 12/526 (2%) in the AV and 1/474 (0.2%) in the MV group. Freedom from reoperation at 6 years was 99% and 95% in the AV and MV group, respectively. Late mortality was 5% in the AV and 3% in the MV group, respectively.
Minimally invasive valve surgery can be performed at very low levels of morbidity and mortality, with results equal to or better than conventional techniques. All forms of valve repair and replacement operations can be performed. Long-term survival and freedom from reoperation are excellent.
Because many gastrointestinal (GI) tumors spread by way of lymphatics, histological assessment of the first draining lymph nodes has both prognostic and therapeutic significance. However, sentinel ...lymph node mapping of the GI tract by using available techniques is limited by unpredictable drainage patterns, high background signal, and the inability to image lymphatic tracers relative to surgical anatomy in real time. Our goal was to develop a method for patient-specific intraoperative sentinel lymph node mapping of the GI tract by using invisible near-infrared light.
We developed an intraoperative near-infrared fluorescence imaging system that simultaneously displays surgical anatomy and otherwise invisible near-infrared fluorescence images of the surgical field. Near-infrared fluorescent quantum dots were injected intraparenchymally into the stomach, small bowel, and colon, and draining lymphatic channels and sentinel lymph nodes were visualized. Dissection was performed under real-time image guidance.
In 10 adult pigs, we demonstrated that 200 pmol of quantum dots quickly and accurately map lymphatic drainage and sentinel lymph nodes. Injection into the mid jejunum and colon results in fluorescence of a single lymph node at the root of the bowel mesentery. Injection into the stomach resulted in identification of a retrogastric node. Histological analysis in all cases confirmed the presence of nodal tissue.
We report the use of invisible near-infrared light for intraoperative sentinel lymph node mapping of the GI tract. This technology overcomes the limitations of currently available methods, permits patient-specific imaging of lymphatic flow and sentinel nodes, and provides highly sensitive, real-time image-guided dissection.
Objective Management of a patent left internal thoracic artery graft during reoperation is controversial. The “no-dissection” technique avoids dissection and clamping of the left internal thoracic ...artery graft, and myocardial protection is achieved using adjunctive systemic hypothermia and hyperkalemia. We compared the postoperative outcomes after isolated reoperative aortic valve replacement in patients with previous coronary artery bypass grafting with a patent left internal thoracic artery graft using a no-dissection technique with the outcomes of patients with previous coronary artery bypass grafting without a left internal thoracic artery graft. Methods The outcomes were analyzed for patients who underwent isolated reoperative aortic valve replacement with previous coronary artery bypass grafting from January 1, 2002, to June, 30, 2011. Patency of the left internal thoracic artery was confirmed using either coronary angiography or computed tomography angiography. The patent left internal thoracic artery group did not undergo dissection or clamping of the left internal thoracic artery graft, and myocardial protection was obtained using systemic hypothermia and hyperkalemia. The no left internal thoracic artery group underwent isolated aortic valve replacement with previous coronary artery bypass grafting but had no left internal thoracic artery graft. Results A total 174 patients were identified for the patent left internal thoracic artery group and 26 for the no left internal thoracic artery group. The perfusion and crossclamp times were similar. No differences were seen between the 2 groups in operative mortality (6.9% vs 7.7%, P = 1.00). The complication rates were similar, and the peak creatine kinase-MB values within 24 hours of surgery were not significantly different between the 2 groups (median, 27.4 vs 29 μ/mL; P = .72). Conclusions Reoperative aortic valve replacement in patients with previous coronary artery bypass grafting and a patent left internal thoracic artery graft can be performed safely without dissection or clamping of the left internal thoracic artery using systemic hyperkalemia and hypothermia. We believe this method prevents unnecessary injury during dissection of the left internal thoracic artery graft.
Certification in cardiothoracic surgical critical care Sherif, Hisham M.F., MD; Cohn, Lawrence H., MD
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
05/2014, Letnik:
147, Številka:
5
Journal Article
The presence of lymph node metastases is an important prognostic marker with regard to non-small-cell lung cancer (NSCLC). Assessment of the sentinel lymph node (SLN) for the presence of tumor may ...improve staging. Our objective was to develop an optical noninvasive imaging tool that would permit intraoperative SLN mapping and provide real-time visual feedback for image-guided localization and resection.
Invisible near-infrared (NIR) light penetrates relatively deeply into tissue and background autofluorescence is low. We have developed a NIR fluorescence imaging system that simultaneously displays color video and NIR images of the surgical field. We recently engineered 15 nm nonradioactive NIR fluorescent quantum dots (QDs) as optimal lymphotrophic optical probes. The introduction of these QDs into lung tissue allows real-time visualization of draining lymphatic channels and nodes.
In 12 Yorkshire pigs (mean weight 35 kg) we demonstrated that 200 pmol of NIR QDs injected into lobar parenchyma accurately maps lymphatic drainage and the SLN. All SLNs were strongly fluorescent and easily visualized within 5 minutes of injection. In 14 separate injections QDs localized to a mediastinal node, whereas in 2 injections QDs localized to a hilar intraparenchymal node. Histologic analysis in all cases confirmed the presence of nodal tissue.
We report a highly sensitive rapid technique for SLN mapping of the lung. This technique permits precise real-time imaging and therefore overcomes many limitations of currently available techniques.
Editor's review and looking forward Cohn, Lawrence H., MD
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
2013, January 2013, 2013-01-00, Letnik:
145, Številka:
1
Journal Article
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