We assessed the impact of coverage of the mediastinum with a local hemostyptic agent as well as the impact of perioperative thromboembolic prophylaxis on cumulative chest drain volume and on the ...duration of chest tubes after surgical resection with complete mediastinal lymph node dissection for stage I or II non–small cell lung cancer.
In a prospective, randomized two-by-two factorial design, 80 patients with clinical stage I or II non–small cell lung cancer were allocated to one of two surgical therapy arms (TachoComb or conventional surgical hemostasis) and one of two anticoagulation arms (enoxaparin 4,000 IU or dalteparin 5,000 IU). Primary end point was cumulative chest drain volume; secondary end point was duration of chest tubes. Additionally clinical data were obtained.
Comparison of the surgical arms revealed significantly lower cumulative chest drain volumes and thereby an earlier chest tube removal in the TachoComb group (
p = 0.045). With regard to thromboembolic prophylaxis, a significantly earlier chest tube removal was found for patients treated with dalteparin (
p = 0.039). Analysis of the interaction of surgical and anticoagulation treatment revealed the combined use of TachoComb and dalteparin was superior to other combinations (cumulative chest drain volumes 498 ± 67 mL versus 1,000 ± 88 mL, 924 ± 87 mL, and 895 ± 118 mL;
p = 0.008; mean duration of chest tubes 1.78 ± 0.15 days versus 2.96 ± 0.21 days, 2.93 ± 0.17 days, and 3.06 ± 0.27 days;
p = 0.019).
The combined use of a local hemostyptic agent and dalteparin seems superior as compared with other regimens of hemostasis and thromboembolic prophylaxis in patients undergoing surgical resection and complete mediastinal lymph node dissection for stage I and II non–small cell lung cancer with regard to cumulative chest drain volume as well as duration of chest tubes.
To evaluate the role of apical lung wedge resection in patients with recurrent primary spontaneous pneumothorax with no endoscopic abnormalities at surgery as compared with simple apical pleurectomy.
...We performed a retrospective analysis on 126 consecutive video-assisted thoracoscopic surgery (VATS) procedures in 113 patients treated for stage I recurrent PSP between January 1994 and December 2001. Two surgical strategies were applied: simple apical pleurectomy (57 procedures, 45.2%: group A) and apical pleurectomy together with an apical lung wedge resection (69 procedures, 54.8%: group B).
Mean duration of chest tubes was 1.4 days (range, 1 to 7), mean hospital stay was 2.4 days. Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax. Mean follow-up was 38.7 months. Overall recurrence rate was 3.2%. Four patients in group A (7%) experienced recurrent ipsilateral pneumothoraces 4 to 73 weeks (mean, 30.2) after surgery. No recurrences were observed in group B (
p = 0.009).
In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even for this favorable category of patients.
Background. The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left ...untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta.
Methods. From April 2001 to February 2002, 8 consecutive patients (3 women 37.5% and 5 men 62.5%) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery.
Results. Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months).
Conclusions. This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.
a Department of Cardiothoracic Surgery, Medical University Vienna, Wäuahringer Gürtel 18-20, A-1090, Vienna, Austria
b Department of Cardiothoracic and Vascular Anaesthesia & Intensive Care, Medical ...University of Vienna, Wäuahringer Gürtel 18-20, A-1090, Vienna, Austria
*Corresponding author. Tel.: +43-1-40400-5620; fax: +43-1-40400-5642. E-mail address : Wilfried.Wisser{at}meduniwien.ac.at (W. Wisser).
The transition to totally endoscopic arterial bypass grafting (TECAB) by computer enhanced instrumentation systems brings the loss of an assisting hand for grasping the pedicle of the internal thoracic artery (ITA) and holding the threads, since only two robotic arms are positioned in the thoracic cavity. That is why exact planning of every step during surgery is mandatory. Especially the positioning of the IMA pedicle during beating heart procedures is imperative for friction-free workflow during the anastomosis. Stay sutures may partially overcome this problem. However, the pedicle hanging on stay sutures still tends to sway around, repositioning is limited. To aid in better workflow, we developed an easy-to-use and cheap holder for the IMA pedicle without the need of any additional port. By inserting a steel wire through the stabilizing system, the pedicle can be easily fixed onto it thus positioned and repositioned wherever it is needed during sewing the anastomosis.
Key Words: Da Vinci; Robotic surgery; TECAB; Beating heart
a Department of Cardiothoracic Surgery, Medical University of Vienna, Leitstelle 20A, AKH Vienna, Währinger Gürtel 1820, 1090 Vienna, Austria
b Department of Cardiothoracic and Vascular Surgery, ...Hospital Hietzing, Vienna, Austria
c Department of Plastic and Reconstructive Surgery, Medical University of Vienna, AKH Vienna, Austria
d Department of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, AKH Vienna, Austria
e Department of Infection surveillance, Medical University of Vienna, AKH Vienna, Austria
*Corresponding author. Tel.: +431404005620; fax: +431404005640. E-mail address : tatjana.fleck{at}meduniwien.ac.at (T. Fleck).
Consensus exists that early recognition of sternal wound infection is crucial to prevent involvement and destruction of the sternal bone, which prohibits secondary sternal closure and necessitates the use of muscle flaps for wound closure. Since November 2001 to September 2005, 125 patients received a VAC system after surgical debridement. Thirty-eight patients had a superficial infection (2A) and 87 patients had a deep infection (2B). From those, 59 patients underwent secondary sternal closure after VAC therapy, whereas 28 patients needed muscle flap closure. The time of diagnosis of sternal infection had great impact on the outcome. It was made on POD 10.6±8.3 in the 2A group, and on POD 13.2±11.1 in the 2B group. In the patients from Group 2A who had a recurrence of infection, the initial diagnosis of infection was made on POD 13.1±11.1. In patients where an SC was possible the time of diagnosis was on POD 11.1±6.6 whereas POD 17.7±16.2 in the MF group. The key to successful management of sternal wound infection is early recognition and aggressive treatment with reopening of the entire wound and sternum, which seems mandatory to achieve a low recurrence rate.
Key Words: Sternal wound infection; Vacuum assisted closure; Secondary closure; Recurrence of infection
It was the aim of this study to compare in vitro closure time (PFA-100), reflecting platelet-related primary hemostasis, to more platelet-specific tests like whole blood electrical aggregometry and ...platelet surface antigen expression in healthy volunteers. In vitro closure time was measured using a PFA-100. Platelet surface antigen expression (CD63, CD62-P, CD42b, CD36, CD31) was determined in accordance with the consensus protocol for flow-cytometric characterisation of platelet function. Platelet aggregometry was performed using a whole blood electrical aggregometer (ADP and arachidonic acid as agonists). Analysis of the obtained data revealed only a few significant correlations between the different platelet function tests used. This finding can be explained by the various aspects of platelet function being focused by these tests in different extents. Whenever platelet function is analysed, the investigator should be aware of the specific and limited evidence of the method used. For screening purposes, it may be useful to introduce a platelet function index, referring to basal platelet activity, platelet adhesion and platelet aggregation at low and high shear stress forces.
Introduction: To evaluate the protective effect and the optimum duration of cerebrospinal fluid drainage (CSFD) during and after thoracoabdominal aortic aneurysm (TAAA) repair.Methods: From April ...2001 to October 2003, we retrospectively compared 17 (n=17) consecutive patients who have been electively operated on by Martin Grabenwoger for left heart bypass and selective perfusion of the visceral and renal organs.Results: The first 7 patients had CSFD for 72 hours; the duration of CSFD was increased to 100 hours in the remaining 10 patients. Median drained cerebrospinal fluid (CSF) volume was 680 milliliters in the 72-hour group versus 1441 milliliters in the 100-hour group. A characteristic increase in CSF volume was noted between POD No. 2 and POD No. 4 indicating persistent spinal cord edema. Univariate and multivariate analysis demonstrated that CSFD for 100 hours is a significant predictor for decreased incidence of late onset paraplegia (p<0.001). The overall incidence of postoperative neurological deficit was 17.6% (3 of 17). There was one patient (6%) who developed permanent paraplegia and two patients (12%) with transient paraplegia. These patients sustained late-onset paraplegia 72 hours after surgery for removal of a CSFD device. Complete motor function could be restored after re-insertion of a CSFD device. In one patient, permanent paraplegia was evident after awakening from anesthesia. Because of technical difficulties, only two intercostal arteries could be re-implanted, which was obviously not sufficient to restore spinal cord perfusion. In contrast, no neurological deficit occurred in patients in whom a CSFD instrument was left for 100 hours.Conclusion: The extended duration of CSFD may lower the risk of late-onset paraplegia and could improve outcome in patients undergoing thoracoabdominal aortic surgery.
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