Minimally invasive surgery for valvular heart disease.

OPINION STATEMENT: Valvular heart disease imposes varying degrees of stress on the myocardium, which, untreated, leads to eventual ventricular dysfunction. The pathophysiologic mechanisms by which these lesions act depend not only on the affected valve, but also the degree to which they causes stenosis, regurgitation, or both. The goal of patient treatment is to identify and correct the defect before irreversible ventricular changes have occurred. Historically, the conventional surgical approach for valvular disease was via median sternotomy. Minimally invasive valve surgery (MIVS) refers to alternative surgical techniques, which avoid the trans-sternal approach. The objective is to (1) minimize surgical trauma, (2) reduce blood utilization, and (3) hasten postoperative convalesce. These goals are accomplished through the use of partial sternal, para-sternal, or thoracotomy incisions and can be adapted to robotic technologies. As with all evolving surgical techniques, the therapeutic aim of valve repair or replacement must be performed at or above the same standard of conventional surgery. Outcomes must not be sacrificed for the sake of better cosmesis. In addition, percutaneous catheter-based valvular interventions have seen rapid advances. These emerging technologies have dramatically broadened the therapeutic options, especially for an ever-increasing group of high-risk patients. As expected with all minimally invasive techniques, the major differences in the hard outcomes of mortality and major morbidity are seen in these highest risk groups. However, intermediate and low risk patients receive a tremendous benefit with regard to shortened hospital stay and quicker functional recovery. With the myriad of interventional options now available, the clinical challenge now is how best to individualize the treatment approach to a given patient providing the most durable result in order to alleviate symptoms and preserve myocardial function.

Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side.

BACKGROUND: During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions. METHODS: Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups. RESULTS: Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05). CONCLUSION: Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed. LEVEL OF EVIDENCE: Basic science.

A comparison of open versus closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery.

BACKGROUND: Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. PURPOSE: The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. METHODS: From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. RESULTS: Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. CONCLUSION: Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

Intestinal fatty acid binding protein (I-FABP) for the detection of strangulated mechanical small bowel obstruction.

OBJECTIVE: Intestinal fatty acid binding protein (I-FABP), a protein released by necrotic enterocytes, is a useful marker for the detection of ischemia from mechanical small bowel obstruction. DESIGN: Validation cohort. SETTING: Academic medical center. PARTICIPANTS: Cohort of 21 patients admitted with a clinical diagnosis of mechanical small bowel obstruction. Plasma and urine samples were collected from patients upon hospital admission and again immediately before laparotomy if surgical intervention was delayed. RESULTS: Plasma and urine I-FABP levels (pg/ml by enzyme-linked immunosorbent assay) in patients found to have small bowel necrosis at the time of laparotomy were compared with those without significant ischemia upon laparotomy and those that did not require laparotomy and, by default, did not have small bowel ischemia. A positive test was defined as 1000-pg/ml I-FABP in urine and 100-pg/ml I-FABP in plasma. Small bowel necrosis was confirmed in 3 of 21 enrolled patients. Urine I-FABP levels were positive in 3 of 3 patients with necrosis and 3 of 18 patients without necrosis (sensitivity 100%, specificity 83%, PPV 50%, NPV 100%). Plasma I-FABP levels were positive in 3 of 3 patients with necrosis and 4 of 18 patients without necrosis (sensitivity 100%, specificity 78%, PPV 43%, NPV 100%). CONCLUSIONS: I-FABP is a sensitive marker for ischemia in mechanical small bowel obstruction. Additional work should be done to validate I-FABP in a variety of clinical settings and to develop a rapid I-FABP laboratory assay.

Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass.

BACKGROUND: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss. METHODS: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN). RESULTS: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group. CONCLUSIONS: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.

Trauma team activation: simplified criteria safely reduces overtriage.

BACKGROUND: Our current trauma triage system uses patient and scene variables within a 3-tiered trauma response system. Our purpose was to evaluate the accuracy of the current system and to identify the most reliable variables for trauma triage. METHODS: This was a retrospective review at a level II trauma center. Multivariate logistic regression was used to identify independent predictors of the need for any urgent emergency department procedure or operative intervention. The current triage system was analyzed and compared with a proposed simplified system. RESULTS: There were 1495 consecutive trauma admissions identified, the majority (88%) were blunt mechanism. Urgent emergency department interventions were required in 11%, and 4% required emergent surgery. Logistic regression demonstrated that prehospital Glasgow Coma Score <14 (odds ratio [OR] 9.7), hypotension (OR 3.3), altered respiratory effort (OR 4.6), and penetrating truncal injury (OR 10.8) independently predicted the need for urgent intervention (all P < .01). The current system undertriaged only 1% but overtriaged 51% of patients. A simplified triage system using these 4 variables significantly decreased overtriage and reliably identified patients with severe injury. CONCLUSIONS: A simplified triage system using only highly predictive variables can safely decrease the high rate of overtriage of trauma patients.