Innovation According to C. Walton Lillehei

C. Walton Lillehei (1918-1999) represents the most distinguished American surgeon of his time and perhaps the greatest surgeon in history. As his mentor, Owen H. Wangenesteen (1898-1981), so accurately declared, Walt Lillehei was "one of the surgical immortals." Indeed, similar words were echoed by the famous cardiac surgeon, Denton A. Cooley (b. 1920), who said, "Hardly any other cardiac surgeon has introduced a greater number of innovative techniques and concepts." Born in Minneapolis, Lillehei attended the University of Minnesota, where he completed his college, medical, physiology, and surgical studies. Because of his extraordinary contributions to make open heart surgery feasible and safe, he is considered the father of open heart surgery. Many other contributions followed the initial innovations, particularly the use of the bubble oxygenator, the total intracardiac repair of tetralogy malformation, the use of myocardial electrodes for treating complete heart block, and the development of three cardiac valve prostheses, among other discoveries. The noted Minnesota surgeon was an innovator for his entire professional career. He believed in innovation and practiced innovation in any way possible. "Determination, persistence, and stubbornness" were, according to Lillehei, "the most important components of research and successful discovery."

Bispectral index monitoring in ischemic-hypoxic brain injury

The BIS monitor is a simple-to-use and widely available monitor used in cardiac surgery. It can provide useful new information regarding the patient's hypnotic state, but also other components of brain function. The detection of cerebral hypoperfusion is of prime importance to perfusionists and others caring for patients undergoing cardiac surgery. BIS values consistent with the anesthetic drug and dose administration should reflect adequate cerebral perfusion and function. Abnormally low or a sudden deterioration in BIS values probably indicate cerebral hypoperfusion and should be taken seriously. A growing number of anecdotal reports and small case series support these contentions, but large prospective outcome studies are needed before this technology can be reliably used to monitor cerebral perfusion and other aspects of brain function during surgery.

[Pleural empyema, chirurgeons and Auenbrugger's Inventum novum]

In the past while the diagnosis was primarily made by the physician, the treatment of thoracic empyema was a surgeon's job. Carrying out this treatment was something of a hit and miss affair. With the change from belief in the Hippocratic principles ofhumours towards organs and tissues being the cause of disease, the way diagnoses were made also changed. The technique of percussing the thorax developed by Auenbrugger two centuries ago, was the beginning of diagnosing based on meticulous physical examination. Chirurgeons were expected to treat thoracic empyema adequately and by employing this technique, were able to make a more exact diagnosis and consequently provide better treatment. Modern imaging techniques have rendered manual thoracic percussion less often necessary. Percussion is now carried out much more often by pulmonologists than by surgeons. Nevertheless, Auenbrugger's 'inventum novum' will continue to be a gratefully employed technique.

Effects of modified ultrafiltration on coagulation as measured by the thromboelastograph

Hemodilution during cardiopulmonary bypass (CPB) continues to be a cause of morbidity associated with coagulation dysfunction, bleeding, and allogeneic blood transfusion. Clot formation and strength have been shown to impact bleeding and transfusions. Strategies to reduce hemodilution may be negated based on the course of the cardiac procedure itself. Modified ultrafiltration (MUF) is commonly used in pediatric cardiac surgery; however, it is not well accepted in adult surgery. This study aimed to evaluate clot formation and strength, bleeding, and transfusions in adult subjects undergoing MUF. Nineteen subjects having primary coronary artery bypass, aortic, or mitral valve surgeries were recruited and randomized to having MUF (n = 10) or no-MUF (n = 9) performed after the termination of CPB. Five time points for data collection were designated: T1, baseline/induction; T2, termination CPB; T3, post-MUF; T4, post-protamine; T5, 24 hours postoperative. Subjects randomized to MUF had 1505 +/- 15.8 mL of effluent removed, and no-MUF subjects had the CPB remnants processed with a cell salvage device. There was no statistical difference seen in 24-hour chest tube output, thromboelastograph values, or allogeneic transfusions at any time point between MUF and no-MUF subjects. There was a significant difference between MUF and no-MUF in the number of autologous cell salvage units processed (1.3 +/- .48 vs. 2.9 +/- .78, p = .0013) and end of procedure net fluid balance (+2003 +/- 1211 vs. +4194 +/- 1276 mL, p = .001), respectively. Estimated plasma loss from the cell salvage device was 477.6 mL greater in the no-MUF group. In primary adult cardiac procedures, MUF did not change coagulation values as measured by thromboelastography, number of allogeneic unit transfusions, or chest tube output at 24 hours postoperatively. There was a significant difference in autologous cell salvage units processed and end of procedure net fluid balance that benefited MUF subjects.

[The use of 19 Fr silicone drains in chest surgery]

We evaluated a single 19 Fr Blake drain after chest surgery retrospectively. 50 patients underwent drainage of their pleural cavity using Blake drains. Blake drain was found to be effective in drainage of both air and fluid. In addition, this soft silicone drain seemed to improve the comfort of the patients. One single Blake drain is considered to be an option for chest drainage in most of general thoracic surgery.

Use of leukocyte-depleting filters during cardiac surgery with cardiopulmonary bypass: a review

Numerous researchers and clinicians have shown that cardiopulmonary bypass (CPB) plays a large role in the initiation of the systemic inflammatory response during cardiac surgery. The activation of leukocytes during this process has been implicated as one of the major contributors to multi-organ dysfunction experienced by some patients after cardiac surgery. Thus, in an attempt to attenuate the systemic inflammatory response and to reduce the amount of activated leukocytes from the systemic circulation during CPB, leukocyte-depleting filters were developed in the early 1990s. Since the clinical introduction of these filters into the CPB circuit, several articles have been published evaluating the effectiveness of leukocyte filtration; however, the results have been conflicting. This article will review some of the most recent literature, approximately 40 papers published within the past 10 years, regarding the use of leukocyte-depleting filters during CPB and its effectiveness in preserving organ function. In addition, the effect of different filtration strategies and the effectiveness of the filter to attenuate the systemic inflammatory response in combination with other mechanical and pharmaceutical strategies will be reviewed.

Modified thoracentesis technique using a triple-lumen catheter

Therapeutic thoracentesis may be preferable over tube thoracostomy in select clinical scenarios in which a symptomatic pleural effusion develops after an isolated and limited physiologic insult. Notable risks in patients undergoing bedside thoracentesis include parenchymal lung injury, abdominal organ injury, and incomplete pleural drainage. These risks are driven in part by inexperienced house officers performing the technique, coupled with technical limitations imparted by hospital-provided thoracentesis kits. To address these concerns, we present a modification to the technique of bedside thoracentesis whereby a triple-lumen catheter is placed into the pleural space over a guidewire. This approach overcomes shortcomings of the packaged thoracentesis kits, improves patient comfort, minimizes the risk of lung injury, and provides more complete drainage of the pleural cavity in patients requiring therapeutic thoracentesis. This approach carries a small risk of air entry into the pleural space, which can be minimized with meticulous technique. Furthermore, by using a Seldinger approach, our technique can improve resident comfort with thoracentesis by drawing on a more robust skill set that likely already has developed during their training in central line placement.

A Decade of Short-Term Outcomes in Post–Cardiac Surgery Ventricular Assist Device Implantation

Background— Previous studies showed 75% mortality before hospital discharge in patients with a ventricular assist device (VAD) placed for post–cardiac surgery shock. We examined a large national clinical database to assess trends in the incidence of post–cardiac surgery shock requiring VAD implantation, survival rates, and risk factors for mortality.

Methods and Results— We identified patients undergoing a VAD procedure after cardiac surgery at US hospitals participating in the Society of Thoracic Surgeons’ National Cardiac Database during the years 1995 to 2004. Baseline characteristics and operative outcomes were analyzed in 2.5-year increments. Logistic regression modeling was performed to provide risk-adjusted operative mortality and morbidity odds ratios. A total of 5735 patients had a VAD placed during the 10-year period (0.3% cardiac surgeries). Overall survival rate to discharge after VAD placement was 54.1%. With the earliest period (January 1995 through June 1997) used as reference, the mortality odds ratio declined to 0.72 (July 1997 through December 1999) and eventually to 0.41 (July 2002 through December 2004; P <0.0001). The combined mortality/morbidity odds ratio also declined, to 0.84 and 0.48 over identical periods ( P <0.0001). Preoperative characteristics associated with increased mortality were urgency of procedure, reoperation, renal failure, myocardial infarction, aortic stenosis, female sex, race, peripheral vascular disease, New York Heart Association class IV, cardiogenic shock, left main coronary stenosis, and valve procedure (c index=0.755).

Conclusions— After adjustment for clinical characteristics of patients requiring mechanical circulatory support, rates of survival to hospital discharge have improved dramatically. Insertion of a VAD for post–cardiac surgery shock is an important therapeutic intervention that can salvage most of these patients.

Surgical Treatment of Atrial Fibrillation: A Look into the Future

The surgical treatment of atrial fibrillation began in 1987, when Dr. James Cox introduced the maze procedure. This operation proved to be extremely effective in curing atrial fibrillation and preventing its most dreaded complication, stroke. However, many surgeons found the operation to be too difficult and invasive. Over the last 5 to 10 years, various groups have tried to develop less invasive approaches using a number of different energy sources to create linear lines of ablation to replace the surgical incisions. This has led to a plethora of new operations for this arrhythmia. There is significant confusion in the literature at the present time as to what is the best lesion pattern and what is the best energy source. It is our feeling that a great deal of this confusion is due to our lack of understanding of the mechanisms of atrial fibrillation and the effect of ablation technology on atrial hemodynamics and electrophysiology. Future progress will require a better understanding of this arrhythmia and continued research into the safety and efficacy of ablation devices.

Ablation of Atrial Fibrillation with Concomitant Cardiac Surgery

Atrial fibrillation is present in approximately 35% of patients presenting for mitral valve surgery and in 1 to 6% of adult patients undergoing other forms of cardiac surgery. If left untreated, atrial fibrillation is associated with increased morbidity, and, in some subgroups, increased mortality. Therefore, concomitant management of the arrhythmia is indicated in most cardiac surgery patients with preexisting atrial fibrillation. Although the cut-and-sew Cox-maze III procedure is extremely effective, it has been supplanted by newer operations that rely on alternate energy sources to create lines of conduction block. Early and mid-term results are good with a variety of technologies. Choice of lesion set remains a matter of debate, but results of ablation appear to be enhanced by a biatrial lesion set. Targeted areas for improvement in concomitant ablation include acceptance of uniform standards for reporting results, development of improved technology for ablation and intraoperative assessment, and creation of instrumentation that facilitates minimally invasive approaches.

A Comparison of Epidural Pressures and Incidence of True Subatmospheric Epidural Pressure Between the Mid-Thoracic and Low-Thoracic Epidural Space

BACKGROUND

Differences in epidural pressure (EP) may influence the spread of blockade in thoracic epidural anesthesia. We evaluated if EP and the incidence of subatmospheric EP differ between the mid- and low-thoracic epidural space.

METHODS

Patients received an epidural catheter at the T3-5 (MID group, n = 20) or T7-10 (LOW group, n = 20) intervertebral space, respectively. The epidural space was identified using a Tuohy needle connected to a pressure transducer, after which EP was measured.

RESULTS

The epidural space could not be identified in three patients who were excluded from the study. EP data are presented as median value (interquartile range). Median EP was 1 mm Hg (-1 to 4.5) in the MID group, and 4 mm Hg (2-7.8) in the LOW group (P = 0.04). The incidence of an EP <or=0 mm Hg was 8 of 17 patients in the MID group and 2 of 20 patients in the LOW group (P = 0.02).

CONCLUSIONS

We conclude that EP is lower, and the incidence of subatmospheric EP is higher in the mid-thoracic epidural space when compared with that in the low-thoracic epidural space. However, median EP was positive in both groups. It remains to be investigated whether this pressure gradient is sufficient to influence the spread of thoracic epidural blockade.

A Simple Training Model for Coronary Artery Anastomoses

To provide supplementary training for trainee cardiac surgeons, a simple method is required to simulate coronary anastomoses. By stretching 2 gloves over a towel, a model can be made that can be used to simulate a small coronary arteriotomy (including anterior and posterior walls). The graft can also be simulated using the fingers of the gloves.

Transapical transcatheter aortic valve implantation in humans: initial clinical experience

BACKGROUND

Aortic valve replacement with cardiopulmonary bypass is currently the treatment of choice for symptomatic aortic stenosis but carries a significant risk of morbidity and mortality, particularly in patients with comorbidities. Recently, percutaneous transfemoral aortic valve implantation has been proposed as a viable alternative in selected patients. We describe our experience with a new, minimally invasive, catheter-based approach to aortic valve implantation via left ventricular apical puncture without cardiopulmonary bypass or sternotomy.

METHODS AND RESULTS

A left anterolateral intercostal incision is used to expose the left ventricular apex. Direct needle puncture of the apex allows introduction of a hemostatic sheath into the left ventricle. The valve prosthesis, constructed from a stainless steel stent with an attached trileaflet equine pericardial valve, is crimped onto a valvuloplasty balloon. The prosthetic valve and balloon catheter are passed over a wire into the left ventricle. Positioning within the aortic annulus is confirmed by fluoroscopy, aortography, and echocardiography. Rapid ventricular pacing is used to reduce cardiac output while the balloon is inflated, deploying the prosthesis within the annulus. Transapical aortic valve implantation was successfully performed in 7 patients in whom surgical risk was deemed excessive because of comorbidities. Echocardiographic median aortic valve area increased from 0.7 +/- 0.1 cm2 (interquartile range) to 1.8 +/- 0.8 cm2 (interquartile range). There were no intraprocedural deaths. At a follow up of 87 +/- 56 days, 6 of 7 patients remain alive and well.

CONCLUSIONS

This initial experience suggests that transapical aortic valve implantation without cardiopulmonary bypass is feasible in selected patients with aortic stenosis.

Pediatric cardiopulmonary bypass devices: trends in device use for cardiopulmonary bypass and postcardiotomy support

Cardiopulmonary bypass (CPB) devices and techniques have continuously evolved. We have conducted surveys that chronicle the changes in CPB devices and techniques used at North American pediatric cardiac surgery centers since 1989. The aim of this article is to describe trends in cardiopulmonary bypass device use during cardiac surgery and changes in the devices used for extracorporeal life support (ECLS) following cardiac surgery for pediatric patients. The diffusion of innovation in pediatric cardiovascular surgery has not been solely driven by the availability of scientific evidence to support change but rather it has often been related to other factors that influence clinicians willingness to change including; tradition, ease of use, and cost related pressures. The current CPB systems used for cardiac surgery are more homogenous than in previous years. Most centers use a heparin coated or modified surface system comprised of a "hard shell" open venous reservoir, a roller pump, a hollow fiber membrane oxygenator, and arterial line filter. ECLS systems comprised of hollow fiber oxygenators and centrifugal pumps for are gradually replacing the classical ECLS circuit, servo regulated roller pumps and silicone rubber membranes. Nearly 40% of centers use these alternate components in their ECLS systems. Costs, utility, safety and measurable benefit to the patient should guide decisions related to device selection.

2004 survey of ECMO in the neonate after open heart surgery: circuitry and team roles

Over the past 20 years, the bulk of the literature and texts published about extracorporeal membrane oxygenation (ECMO) has been written by physicians and nurses. The consensus of this body of printed information would suggest, among other things, that (1) despite significant advancements in extracorporeal technology, the standard ECMO circuit has remained fundamentally unchanged since originally described in 1982, and (2) perfusionists are nearly absent from the staffing algorithm at most centers. While these conclusions may be representative of the extracorporeal life support (ELSO) reporting centers, they may not be representative of the field as a whole. We hypothesized that the use of modern extracorporeal equipment and the involvement of perfusionists in ECMO patient care is largely underreported in previous studies. To study this hypothesis, we developed a standard survey instrument and queried perfusion teams from the hospitals listed on the American Society of Extra-Corporeal Technology Pediatric Registry. All centers were contacted by phone and were asked questions regarding their caseload, circuitry, and staffing algorithms. Data are reported as a percentage of respondents. ECMO is used as a method of mechanical support after neonatal open heart surgery in 94% of centers surveyed. For 60% of the centers, a silicone membrane oxygenator is used exclusively, whereas 40% of the centers have used a hollow fiber oxygenator (HFO), and of that group, 19% use a HFO routinely for neonatal post-cardiopulmonary bypass ECMO. Roller pumps are used exclusively at 65% of the centers, whereas centrifugal pumps are used routinely in 12%, and 23% have used both. Perfusionists are responsible for set-up/initiation (79%) and daily rounding/troubleshooting (71%), and provide around-the-clock bedside care (46%) at the surveyed centers. These data suggest that previously published ELSO-centric ECMO studies may significantly underestimate the contemporary application of modern technologies and the involvement of perfusionists.

A prospective comparison of the platelet sequestration ability of three autotransfusion devices

Although current autotransfusion devices have platelet sequestration capabilities, each has a unique technology to achieve the final platelet product. The purpose of this study was to assess the quality and quantity of platelets sequestered by three different autotransfusion devices. The three commercially available autotransfusion devices evaluated were Fresenius C.A.T.S (closed spiral chamber), Cobe BRAT 2 (Baylor bowl), and Haemonetic Cell Saver 5 (Latham bowl). Platelet sequestration was preformed in the automatic mode following the manufacturer's recommended sequestration protocols. The total number of platelets sequestered, percent recovery, and percent platelet function were assessed. Each device behaved similarly. There was a 2- to 3-fold increase in platelet count compared with baseline with only approximately 50-60% recovery, whereas there was approximately a 10% decrease in platelet function after processing compared with baseline. No statistical difference was noted in platelet function between the respective machines. However, there was a significant loss of platelet function observed with the actual process regardless of autotransfusion device used.

Strategic savings. As supply costs climb, hospitals rethink their purchasing strategies

Surging prices for supplies are intensifying the pressure on hospitals already reeling from skyrocketing liability, staffing and technology costs. The prices for certain supplies far outstrip general inflation and, executives say, could undermine the financial viability of some service lines. That's forcing some hospitals to rethink their purchasing strategies.

Use of covered Cheatham-Platinum stents in aortic coarctation and recoarctation

We inserted covered Cheatham-Platinum stents in 4 patients, ranging in age from 12 to 19 years, who weighed between 45 and 94 kg. All the patients had aortic coarctation, with surgical repair having been attempted previously in one, and with balloon dilation having been performed as the primary treatment in two, resulting in formation of aneurysms. The fourth patient had not received any treatment. The gradients were reduced from 10 to 40 mmHg before insertion of the stent to 0 to 5 mmHg after stenting. No complications were encountered. All the patients are well at an interval of 3 to 14 months after stenting.

The evolution of the helical reservoir pump-oxygenator system at the University of Minnesota

Open heart surgery was not possible before the early 1950s. The development of controlled cross-circulation at the University of Minnesota in 1953 was a major contributing factor toward operating safely on the interior of the heart. Cross-circulation required connecting a donor's arterial and venous blood vessels to those of a smaller recipient whose heart could then be opened for corrective surgery. At that time no mechanical system was available to serve the role of the donor. The need to replace the donor was recognized. The author describes his experience with the development of the helical reservoir bubble oxygenator, which replaced the donor in cross-circulation supported open heart surgery. Other sidelights of the author's experience during the early days of open heart surgery at the University of Minnesota Department of Surgery are also recounted.

["Computer- and Sensor-Assisted Surgery" Special Research Area 414--goals and concepts]

This paper presents an overview of our research in computer assisted surgery within the "Sonderforschungsbereich 414--Information Technology in Medicine: Computer and Sensor Supported Surgery". The overall goal is to achieve improved operation methods including higher quality, more safety and also more economy due to shorter operation time and less postoperative treatment. The SFB 414 is divided into three different sections focusing on projects concerning the heart, projects supporting cranio-facial interventions and interconnecting projects that serve both categories.

[Miniature assistance module for robot-assisted heart surgery]

During the robotic enhanced minimally invasive cardiac surgery the approach to and the space for handling instruments in the operating field are usually reduced, compared to the conventional surgery. Additional well knewn problems are the restricted capability available for accessories into and out of the closed chest and the limited assistance during the cardiac procedure. This paper is presenting two solutions of Miniature Modules for supporting the surgeon inside the closed chest. A self-sufficient Cargo Module is developed as a transportation and depot device. It provides an "inside equipment store" for the surgeon. With the Assist Module the surgical equipment, tissue and vessels can be positioned on a desired place in the operating field. This module provides the surgeon an "assistant" inside the closed chest.

Robotic cardiac surgery

The health care climate is evolving due to influences of new technology, and robotic surgery has become a part of many surgical procedures and specialties. Incorporation of robotic procedures in cardiac surgery has several recognized benefits for patient outcomes, including a smaller incision, decrease in pain, and shorter hospital stay. Increased use of robotics will influence how nurses educate and care for their patients and the types of health care options that will be offered to patients in the future.

Use of an ultrasonic scalpel in the open-heart reoperation of a patient with pacemaker

Electrocautery has a potential risk of serious pacemaker dysfunction in patients with implanted pacemaker. Here we present the safe and efficient use of ultrasonic scalpel (Harmonic scalpel) for the first time in a patient with implanted pacemaker undergoing open-heart reoperation.

All pumped up over cardiology

Cardiovascular services are one of the few remaining profit centers for hospitals, and as baby boomers age, the need for such care is skyrocketing. A good cardiology program enhances a hospital's reputation and patient volume. However, the pressures to expand and the cost of swiftly changing technology put hospitals that are trying to keep up in a tight squeeze, which raises the question: is the pulse of change in cardiology too rapid?

Ernst Ferdinand Sauerbruch: rise and fall of the pioneer of thoracic surgery

Ferdinand Sauerbruch (1875-1951) was a pioneer of thoracic and cardiac surgery and is undoubtedly one of the twentieth century's most outstanding surgeons. Before 1904 operations on the thorax met with fatal complications due to pneumothorax. Sauerbruch developed a pressure-differential chamber that maintained normal respiration and enabled safe operations to be undertaken on the thorax. Together with von Mikulicz, he initiated intrathoracic operations and later developed various surgical procedures on the mediastinum, lungs, pericardium, heart, and esophagus. The simple yet effective techniques of positive-pressure ventilation replaced the expensive, cumbersome negative-pressure chamber. Sauerbruch's latter years were marred by dementia that adversely affected his personality, intellect, and capacity as a surgeon. The unjustifiable toll of increasing patient morbidity and mortality forced authorities to dismiss him in 1949. He died at the age of 76 in Berlin. After almost a century since the advent of the first safe thoracic surgery, the advances in technique and technology have been enormous. A great deal is owed to the inspiration and contributions of Ferdinand Sauerbruch.

Digital trainer developed for robotic assisted cardiac surgery

Robotic systems for cardiac surgery have been introduced in clinical trials to facilitate minimally invasive techniques. Widespread use of surgical robotics necessitates new training methods to improve skills and continue practicing as the robotic systems are frequently being upgraded. Today, robotic training is performed on expensive animal models. An integration of a digital trainer with the two present robotic systems applied in coronary artery bypass procedures on beating heart requires real time simulation of tissue mechanics, sutures, instruments and bleeding. However, it requires no extra haptic device, since the robotic master is the haptic apparatus itself. By developing new data structures and parametric geometry descriptions we have demonstrated the possibility of obtaining surgical simulation on a standard PC Linux system. This technology is beneficial when simulation is exploited over a network with limited bandwidth, especially when it comes to the handling of soft tissue dynamics.

[A tube retractor for cardiac surgery]

A retractor exclusively used to retract the tubes in cardiac surgery which needs cardiopulmonary bypass was developed. The half-cylinder-shaped end, the lightly curved handle and the flat and triangular grip enable easy and effective grasp of the tubes. This new instrument facilitates operative procedures by effectively retracting the tubes which persistently obstruct the operative field, in such a case of placement of a retrograde cardioplegia tube via the right atrium.

[Two scientific controversies shaping the development of surgery in the 20th century]

By way of example, two scientific controversies that played a decisive role in shaping and determining the development--in the areas of chest and trauma surgery--of 20th century surgery, were discussed. In the former area, the spectacular method involving the use of a negative-pressure chamber, developed by Sauerbruch in 1904 was described--an innovation representing an enormous step forward in the field of surgery on the chest. However, the method failed to find widespread favour, and the opposite concept involving the use of positive-pressure was developed, and intratracheal ventilation--already under discussion at the beginning of the 20th century--finally won the day, and still remains in use. Medullary nailing of bone fractures as introduced by Küntscher initially prompted controversial discussion and at first appeared to have been rejected--only to find widespread acceptance nevertheless. It continues to be a justified method of achieving a stable osteosynthesis which, thanks to methodological refinements and improvements over the years, is an important option in the list of indications for surgical treatment of bone fractures. All in all, the following remark would appear applicable: An achievement alone does not suffice--someone is needed to recognize and endorse it.

[Thymic carcinoid: a case report of complete surgical resection using internal mammary artery (IMA) retractor]

Carcinoid tumor of the thymus is a rare tumor and discovered not infrequently at advanced stage. A 56-year-old male was admitted to our hospital with severe chest pain. Chest X-ray film and CT scan, revealed a tumor mass in the anterior mediastinum. The patient underwent extended thymectomy including tumor completely through median sternotomy in combination with partial resection of pericardium, mediastinal pleura and left upper lobectomy using internal mammary artery (IMA) retractor. The microscopic findings of the tumor revealed carcinoid Invasion to pericardium and lung was found microscopically. After the operation he has been treated by radiotherapy and any regrowth of the tumor has never been detected for 32 months. This case who had been undergone complete resection using IMA retractor followed by radiotherapy seemed to have better prognosis. Accordingly, extended thymectomy including tumor should be carried out for thymic carcinoid, and the IMA retractor is useful for complete surgical resection through median sternotomy.

Video assisted thoracoscopic surgery (VATS) in Asia--its impact and implications

BACKGROUND

Within a short period of time, video assisted thoracoscopic surgery (VATS) has revolutionised the practice of thoracic surgery. Most of the existing literature, however, is concentrated on the technical aspects.

AIMS

We examined the impact of VATS on our practice and its implications.

METHODS

We reviewed our thoracic case load two years before and two years after the introduction of VATS in our hospital.

RESULTS

We have witnessed a rapid and progressive increase in our thoracic case load since the introduction of VATS. With increased experience, proportionally more cases were performed using VATS compared to conventional surgical access. The increased case load covered a wide range of thoracic diseases with the majority for spontaneous pneumothorax and pleural diseases.

CONCLUSIONS

The higher case load is due to increased referrals which at least partly reflect earlier acceptance by both the patients and their physicians for surgical intervention. The changing indications for surgery and the high cost associated with VATS, however, could place extra demand on the healthcare, especially for some countries in Asia. Cost containment is therefore a high priority here. More research is greatly needed in this area.

Thoracic surgery techniques of Serefeddin Sabuncuoğlu in the fifteenth century

Serefeddin Sabuncuoğlu (1385 to 1470?) is known to be the author of the first surgery textbook, namely Cerrahiyyet'ül Haniyye (Imperial Surgery), written in Turkish in 1465. It is the first book to contain colored illustrations of surgical procedures, incisions, and instruments in the Turkish-Islamic medical literature. He was the first man to illustrate and mention introduction of a tube into the pharynx and upper esophagus, removal of foreign bodies in the esophagus by special instruments of his own design, and use of a silver ringlet in a man after tracheotomy. He also described and illustrated reduction of sternal fractures, thoracic puncture through the intercostal space for drainage of empyema cavities, and treatment of rib fractures that have severed the diaphragm. He was a humble, curious, and intelligent surgeon, and also a calligrapher and a miniature artist.

Lobectomy by video-assisted thoracic surgery for a hilar bronchial carcinoid tumor

A 45-year-old man with bronchial carcinoid arising from the subsegmental middle-lobe bronchus was treated by video-assisted thoracic surgery. Lobectomy with mediastinal and hilar lymph node sampling was successfully performed in this patient. To obtain a tumor-free surgical margin on the middle-lobe bronchus, the interlobar pulmonary artery was retracted posteriorly, the middle-lobe bronchus anteriorly. The bronchus was then stapled and transected.

Videothoracoscopy an effective method for evaluating and managing thoracic trauma patients

BACKGROUND

The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients.

METHODS

The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2).

RESULTS

The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient.

CONCLUSIONS

Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.

Dr. Norman Bethune as a surgeon

Dr. Norman Bethune's recognition as a Canadian of renown resulted from his devoted work in China during the late 1930s. He had received a general surgical training, but his personal illness with tuberculosis led him to specialize in thoracic surgery. A surgical program at McGill University under Dr. Edward Archibald, a pioneer thoracic surgeon, was initially successful, but by the mid-1930s Bethune was rejected by McGill and Dr. Archibald. He became chief of thoracic surgery at the Hôpital du Sacré-Coeur outside Montreal. H developed thoracic surgical instruments and wrote numerous scientific papers. The outbreak of civil war in Spain in 1937 attracted Bethune to oppose what he viewed as fascist aggression. He went to Spain, where he established the value of mobile blood banking. On his return to Canada in 1937 he became aware of the escalating war between China and Japan. He joined the Chinese communist forces in northern China and spent 18 months doing Herculean mobile war surgery, while improving the state of medical services in primitive, depressing conditions. He died in 1939 at the age of 49 years of septicemia as a result of accidental laceration of his finger during surgery. The Chinese have venerated Norman Bethune and stimulated his memorialization in Canada. His surgical record can be viewed as mixed in quality, but overall his performance remains impressive for its achievement.