Dynamic aortomyoplasty: clinical experience and thoracoscopic surgery feasibility study.

BACKGROUND: Surgical procedures using the latissimus dorsi (LD) muscle to assist chronic heart failure inflict major trauma on severely sick patients. A less invasive approach may prove beneficial. The aim of this article is to review our clinical and experimental approaches of dynamic aortomyoplasty (AMP) and emphasize the necessity to reorient surgical technique towards new directions and a less invasive thoracoscopic approach. MATERIALS AND METHODS: A clinical pilot study on dynamic descending AMP started in June 1995 and included four patients. Two of them could benefit from LD counterpulsation, surviving 6 months and 18 months. Following this clinical experience, we investigated, on an animal model, minimally invasive thoracoscopic surgery for this procedure. Twelve goats underwent endoscopic LD harvest and video-assisted aortic wrap, and were studied after surgical recovery from an anatomical and functional standpoint. RESULTS: Clinical AMP using open techniques provided extraaortic counterpulsation in NYHA Class IV patients contraindicated for other surgical therapies. However, surgical technique and strategy needed improvements for optimal cardiac assistance and better patient outcome. Minimally invasive thoracoscopic surgery was feasible and reproducible in goats, achieving improved anatomy and physiology as compared to the open technique in humans. When appropriate the wrapping technique and stimulation protocol were used, an optimal counterpulsation was demonstrated. We concluded that thoracoscopic AMP may provide a minimally invasive approach to cardiac assistance and thus, a new surgical option for patients presenting with chronic heart failure.

Innovative techniques in skeletal muscle cardiac assistance: first experimental study on minimally invasive aortomyoplasty and cardiomyoplasty.

Skeletal muscle cardiac assistance as a treatment modality for heart failure is considered a high-risk procedure subject to strict patient selection. The aim here is to develop minimally invasive techniques to improve surgical outcomes and increase clinical indications. Ten goats (45-55 kg) were studied. In six, the latissimus dorsi muscle (LDM) was harvested via an open technique on one side vs a minimally invasive technique on the other using video assistance through two 3 cm incisions. Surgical maneuvers and length of procedures were noted. Animals were recovered, observed daily for local complications, and killed after 1 week for comparative anatomic and histopathologic studies. In four other goats, minimally invasive aortomyoplasty or cardiomyoplasty was performed using video assistance (2 aortomyoplasty, 2 cardiomyoplasty). In this experimental series, there were no surgical complications. The minimally invasive LDM harvest required a mean of 81 min (range 55-116 mn) with no gross evidence of muscle damage. The technique of LDM harvesting was standardized and is reproducible. Aortic and cardiac wraping were also achieved through three ports and a left minithoracotomy of 4 cm, using the right or left LDM. A scarf technique for the descending aortomyoplasty using the left LDM, and an anterior wrapping for cardiomyoplasty using the left or right LDM was technically feasible with video assistance. This study suggests future clinical applicability.

Does aggressive medical therapy for acute ulcerative colitis result in a higher incidence of staged colectomy?

BACKGROUND: Colectomy with ileal pouch-anal anastomosis is the operation of choice in patients with medically refractory ulcerative colitis. However, aggressive or prolonged medical treatment may result in the patient's needing an urgent operation in which a staged subtotal colectomy is necessary. OBJECTIVE: Our hypothesis is that the incidence of patients requiring a staged approach has increased, along with an increase in hospital stay and total hospital costs. DESIGN: We examined the medical records of 250 consecutive patients with ulcerative colitis who underwent ileal pouch-anal anastomosis between 1984 and 1993. RESULTS: Simultaneous colectomy and ileal pouch-anal anastomosis were performed in 196 patients (78%), while 54 patients (21.6%) required staged subtotal (78%) or partial colectomy (22%). Indications for initial colectomy included failure of medical therapy (42 patients [77.8%]), undifferentiated colitis (five patients [9.3%]), and perforation (six patients [11.1%]). An increase in the incidence of patients requiring staged colectomy during this period was observed (P < .05). Staged procedures led to a prolonged hospital course at a significantly greater total cost. CONCLUSION: We conclude that aggressive medical therapy of acute ulcerative colitis has increased the incidence of urgent staged colectomy with a resulting increase in morbidity, hospital stay, and cost and a less-optimal functional result.

Counterregulation of a prokinetic calcium-dependent mechanism by cAMP-dependent agents in isolated segments of terminal ileum.

The ill-understood complex of the irritable bowel syndrome comprises a group of intestinal motility disorders characterized by increased intraluminal pressures and decreased transit times. Elucidation of mechanisms which modulate gut motility may lead to the development of rational therapy for this prevalent problem. The purpose of this study was firstly to evaluate the interaction of cAMP-dependent agents (vasoactive intestinal polypeptide (VIP), norepinephrine (NE), and forskolin (FK)) on carbachol (Ca2+)-initiated motility and secondly to determine if a neural component of motility modulation existed by testing if the effect of cAMP-dependent agents was reversed by tetrodotoxin-induced neural blockade. Motility was measured in isolated segments of terminal ileum harvested from rabbits using perfusion manometry and quantitated by integration, expressed as mm Hg/min. Carbachol caused a concentration-dependent increase in measured motor activity (half-effective dose = 10(-7) M). VIP, NE, and FK each caused a concentration-dependent inhibition of carbachol-stimulated phasic contractions. TTX 10(-6) M failed to block the inhibitory actions of NE. In conclusion, these results suggest that cAMP-dependent mechanisms may inhibit gut motility induced by a cholinergic (Ca2+)-mediated agonist and that this process is mediated by a nonneural mechanism.