Vulval cancer, 1992-2002 audit--multidisciplinary care and prognostic factors.

Vulval carcinoma is becoming increasingly common. Thirty-four cases of vulval carcinoma were treated from 01/01/1992-31/12/2002. The mean age was 67, range (18-90). The presenting complaints were "a lump" (76%)(25/33), "itch" (49%)(16/33), "discomfort" (30%)(10/33) and postmenopausal bleeding (21%)(7/33). Most patients presented with stage 1 or 2 disease (73%) (n = 24/33). The majority (97%) (32/33) underwent surgical treatment. Five-year survival was 61% (17/28), (disease-free survival 76% (13/17)). There were 12 cases of local/regional recurrence. Survival rates deteriorated with stage of disease. Lymph-node results, lowered survival from 79% (11/14), if negative, to 17% (1/6) if positive. Age >70 reduced survival from 69% (11/16) to 50% (6/12). We conclude that age, the stage of disease, and lymph-node status were important prognostic factors. The favourable outcomes reflect muItidisciplinary care--combining clinical examinations with regular home contact with specialist nurses, by telephone.

[Clinical experience in thoracoscopic left internal mammary artery harvesting with voice activated robotic assistance].

Between September 1998 to February 2000, 45 consecutive patients underwent robotic-assisted, video-enhanced coronary artery bypass grafting. All IMA's were harvested using the voice-activated robotic assistant (AESOP 3000, Computer Motion Inc, Santa Barbara, CA) and the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Left IMA's were successfully harvested in all patients. Harvested IMA's were anastomosed to LAD's under direct vision through limited left anterior thoracotomy. The IMA harvest time was 57.8 +/- 23.2 min, intraoperative graft flow was 34.3 +/- 20.5 ml/min, postoperative hospital stay was 3.9 +/- 1.5 days. The early postoperative angiogram showed that all grafts were patent. There was no mortality, no significant morbidity. The robotic assisted, video enhanced CABG provides safe and complete LIMA dissection with minimal manipulation and assures sufficient LITA length for tension free anastomosis.

Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting.

BACKGROUND: Use of the sequential probability cumulative sum (CUSUM) technique may be more sensitive than standard statistical analyses in detecting a cluster of surgical failures. We applied CUSUM methods to evaluate the learning curve after a policy change by a single surgeon from routine on-pump (cardiopulmonary bypass [CPB]) to off-pump coronary artery bypass grafting (OPCAB). METHODS: Fifty-five consecutive first-time coronary artery bypass patients (CPB group) were compared with the next 55 patients undergoing an attempt at routine OPCAB using the same coronary stabilizer. The goal in OPCAB patients was to obtain complete revascularization, albeit with a low threshold for conversion to CPB to maximize patient safety during the learning curve. Preoperative patient risk was calculated using previously validated models of the Cardiac Care Network of Ontario. The occurrence of operative mortality and nine predefined major complications (myocardial infarction, bleeding, stroke, renal failure, balloon pump use, mediastinitis, respiratory failure, life-threatening arrhythmia, and sepsis) was compared between the CPB and OPCAB groups using Wilcoxon, Fisher exact, and two-tailed t tests, as well as CUSUM methodology. An intention to treat analysis was performed. RESULTS: The CPB and OPCAB groups had similar predicted mortality and length of stays (2.2% +/- 2.5%, 8.1 +/- 2.5 days versus 2.4% +/- 3.5%, 8.1 +/- 2.4 days, respectively). The mean number of grafts per patient was 3.1 +/- 0.7 in the CPB group versus 3.0 +/- 0.7 in the OPCAB group (p = 0.45). Two of 55 (3.6%) CPB patients died, as opposed to 1 of 55 (1.8%) OPCAB patients (p = 0.99). Eight of 55 CPB patients (14.5%) incurred major complications, as opposed to 4 of 55 (7.3%) OPCAB patients (p = 0.36). Median hospital length of stay was 6.0 days in the CPB group versus 5.0 days in the OPCAB group (p = 0.28). On CUSUM analysis, the failure curve in CPB patients approached the upper 80% alert line after eight cases, whereas the curve in OPCAB patients reached below the lower 80% (reassurance) boundary 28 cases after the policy change, indicating superior results in the OPCAB group despite the learning curve. CONCLUSIONS: A policy change from coronary artery bypass on CPB to routinely attempting OPCAB can be accomplished safely despite the learning curve. CUSUM analysis was more sensitive than standard statistical methods in detecting a cluster of surgical failures and successes.

RAVECAB: improving outcome in off-pump minimal access surgery with robotic assistance and video enhancement.

OBJECTIVE: To determine the efficacy of using the harmonic scalpel and robotic assistance to facilitate thoracoscopic harvest of the internal thoracic artery (ITA). DESIGN: A case series. SETTING: London Health Sciences Centre, University of Western Ontario, London, Ont. PATIENTS AND METHODS: Fifteen consecutive patients requiring harvest of the ITA for coronary artery bypass grafting. INTERVENTION: Robot-assisted, video-enhanced coronary artery bypass (RAVECAB) through limited-access incisions, using the harmonic scalpel and a voice-activated robotic assistant. MAIN OUTCOME MEASURES: Ease and duration of the harvesting technique, complications of the procedure, graft flow and patency, and duration of postoperative hospitalization. RESULTS: RAVECAB facilitated thoracoscopic dissection of the ITA with the harmonic scalpel in all cases. There were no conversions to a standard approach and no reoperations for bleeding. The mean (and standard deviation) ITA harvest time was 64.1 (22.9) minutes (range from 40 to 118 minutes). Robotic voice command capture rate was greater than 95%. Mean (and SD) intraoperative graft flows were 33.1 (26.8) mL/min (range from 14 to 126 mL/min). There was 100% graft patency on postoperative angiography. There were no deaths, perioperaive myocardial infarction or arrhythmias. Mean (and SD) postoperative hospitalization was 3.3 (0.8) days. CONCLUSIONS: RAVECAB is a demanding procedure that addresses many of the disadvantages of the "conventional" minimally invasive coronary artery bypass. It allows complete pedicle dissection with minimal ITA manipulation and assures sufficient conduit length and a tension-free coronary artery anastomosis. All anastomoses were performed under direct vision through a 5- to 8-cm inferior mammary incision.

An alternative arterial conduit for totally endoscopic multivessel coronary artery bypass.

BACKGROUND: The ultimate goal of coronary artery bypass grafting (CABG) is the performance of a totally endoscopic procedure using multiple arterial conduits. At our center we have been routinely performing endoscopic robotic harvesting of internal thoracic arteries (ITAs) for use in minimally invasive CABG. The right gastroepiploic artery (RGEA) has been shown to be a reliable and versatile arterial conduit for bypass to coronary vessels not easily accessible by an ITA. The RGEA has already been harvested less invasively through a small laparotomy. This procedure could be made even less invasive by harvesting the RGEA laparoscopically, but this procedure has not yet been reported. The purpose of this study was to develop an endoscopic technique for harvesting the RGEA and demonstrate the safety and efficacy of this less invasive approach. METHODS: Twenty Duroc X Hampshire swine were administered general anesthesia and intubated. Ten mm and 5 mm trocars were then inserted. A 10 mm, 30-degree endoscope was adapted to a voice-activated robotic arm (AESOP), and the RGEA was harvested totally endoscopically using 5 mm harmonic scalpel shears. Intraoperative events and RGEA harvest times were recorded, and RGEA flows were measured after harvest. RGEA was delivered into the pericardial sac endoscopically. RESULTS: All RGEAs were successfully harvested without injury. Harvest time averaged 29.9+/- 10.9 min. The harvested conduits averaged 24.7+/- 2.37 cm in length. Flows were excellent in all harvested conduits, averaging 81.1+/- 31.8 cc/min. The harmonic scalpel controlled all RGEA branches with excellent hemostasis. CONCLUSION: The RGEA can be harvested safely through port access with robotic assistance. This conduit is of sufficient length to be used as an alternative arterial conduit for totally endoscopic multivessel coronary artery bypass.

Robot-assisted computer enhanced closed-chest coronary surgery: preliminary experience using a Harmonic Scalpel and ZEUS.

BACKGROUND: Successful endoscopic harvesting of arterial conduits is critical to the performance of totally endoscopic bypass grafting. Recent success with computer-enhanced robotic systems in the performance of endoscopic single vessel coronary artery bypass (ENDOCAB) has paved the way for developing techniques for multivessel ENDOCAB. The Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) has previously demonstrated versatility and efficacy in manual endoscopic internal thoracic artery (ITA) harvesting. This study was undertaken to determine the feasibility of adapting this technology to a robotic telemanipulation system and its safety and efficacy in telerobotic ITA harvesting. METHODS: The Harmonic Scalpel was adapted to the ZEUS robotic surgical system (Computer Motion, Goleta, CA) and used to harvest the ITA in 19 patients undergoing multivessel off-pump coronary artery bypass (OPCAB) surgery. With the left lung collapsed, the ITA was harvested in all patients with CO2 insufflation through three 5 mm ports in the left chest. Postoperative angiography and transthoracic Doppler studies were performed in all patients. RESULTS: There were no ITA injuries and patients tolerated insufflation without hemodynamic compromise. Side branches were controlled easily without bleeding. Average ITA harvest time was 65 +/- 21 minutes. All vessels were patent after harvesting and demonstrated no angiographic evidence of injury. CONCLUSIONS: This paper demonstrates a technique by which the Harmonic Scalpel can be readily adapted to the ZEUS robotic telemanipulation system. Using this system, ITA's can be safely harvested totally endoscopically within a reasonable time frame for patients undergoing ENDOCAB.

3-D image guidance for minimally invasive robotic coronary artery bypass.

BACKGROUND: The introduction of a robot-assisted microsurgical system has made endoscopic coronary artery bypass grafting (ECABG) possible. Despite the success of this approach, surgeons still require better visualization tools for pre-surgical planning and intra-operative image guidance. Such visualization tools could, for example, assist in the placement of thoracic ports to acquire optimum access to the target vessels. In this paper we discuss the essential steps toward image-guided completely endoscopic coronary bypass surgery with robot assistance, and we present our preliminary efforts toward the development of a three-dimensional (3-D) virtual cardiac surgical planning platform (VCSP) for ECABG. METHODS: Preoperative 3-D images of the thorax acquired with computed tomography and electrocardiogram-gated magnetic resonance imaging are imported into VCSP. Using VCSP, a user may interactively visualize and manipulate the simulated thoracic ports in 3-D within the reconstructed thoracic region. We have also implemented a virtual endoscope to simulate the endoscopic view observed by the surgeon during the operation. Once the port placements for optimal access to the target vessels are determined, the positions of the simulated tools can be recorded and marked on the patient to specify the positions for port incisions. RESULTS: A static thorax phantom was used to verify the port placements obtained from VCSP simulations. The angles and the distances between the ports, the endoscope and the markers that were placed on the surface of the phantom were measured, and the results were compared with those obtained from simulation. The physical measured distances and angles agreed with the simulated results with average errors of 4 mm and 2 degrees, respectively. CONCLUSIONS: The VCSP image-guided surgical system allows a surgeon to visualize a patient's thorax in a 3-D interactive environment for planning surgical procedures, and to determine the optimum port placement based on preoperative 3-D images. However, during an operation, the positions and orientation of the heart and the coronary arteries are changed from their corresponding locations in the preoperative images due to carbon-dioxide insufflation, lung deflation, and dynamic motions of the beating heart. One of our future goals of this project is the use of mathematical models that correct for these changes so that our system could be applied to intra-operative image guidance.

A comparison of robot-assisted versus manually constructed endoscopic coronary anastomosis.

BACKGROUND: New technology has enabled surgeons to attempt totally endoscopic coronary artery bypass grafting. Our purpose was to compare three different techniques of totally endoscopic anastomosis using a porcine animal model. METHODS: Porcine hearts were excised and the right coronary artery was dissected free for use as an arterial graft. The hearts were placed in a human thoracic model and an endoscopic arterial anastomosis between the free right coronary artery and the left anterior descending coronary artery was performed using one of the following: (1) two-dimensional visualization with straight endoscopic instruments (n = 8); (2) three-dimensional head-mounted visualization with curved endoscopic instruments (n = 7); or (3) three-dimensional visualization with robotic telemanipulation (n = 8). Pathologic analysis of suture placement, vessel trauma, and patency was performed. Anastomoses were graded according to quality, ease, and patency using a seven-point Likert scale (1 = excellent, 7 = very poor). RESULTS: Endoscopic anastomotic ease and quality were significantly improved when three-dimensional visualization and curved endoscopic instruments were employed. Telemanipulation enhanced the process and provided the best operative results with regard to time required to construct the anastomosis, as well as ease and quality. CONCLUSIONS: Totally endoscopic anastomosis is feasible using currently available technology. Three-dimensional visualization and robotic telemanipulation significantly facilitate anastomosis construction and will likely benefit clinical operative outcome.

Three-dimensional video-assisted thoracoscopic pericardiectomy.

Video-assisted thoracic surgery has proven to be safe and effective for the diagnosis and management of pericardial disease. Three-dimensional (3-D) video imaging technology has been developed to allow the laparoscopic surgeon more precision and efficiency in advanced laparoscopic cases. This case report describes the marriage of 3-D video imaging and thoracoscopy that allowed performance of a technically difficult pericardiectomy without incident. Our aim is to describe the use of state-of-the-art 3-D video imaging to allow success in difficult cases.

Off-pump surgery decreases postoperative complications and resource utilization in the elderly.

BACKGROUND: Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients. METHODS: Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65. RESULTS: Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency. CONCLUSIONS: OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.

Beating heart surgery: why expect less central nervous system morbidity?

BACKGROUND: The incidence and etiology of brain dysfunction after conventional coronary artery bypass surgery using cardiopulmonary bypass (CPB) are reviewed. METHODS: Stroke rates and incidences of cognitive dysfunction from various studies are considered. Mechanisms of injury including cerebral embolization as detected by transcranial Doppler and retinal angiography, and imaging-based evidence for postoperative cerebral edema, are discussed. Preliminary results from a prospective clinical trial assessing cognitive dysfunction after beating heart versus conventional coronary artery bypass with CPB are discussed. RESULTS: Initial evidence for lower overall postoperative morbidity, and for a lower incidence of cognitive dysfunction specifically, after nonpump coronary revascularization is presented. CONCLUSIONS: Beating heart surgery results in less potential for generation of cerebral emboli and appears to produce a lower incidence of cognitive dysfunction in both short- and intermediate-term postoperative follow-up periods as compared with conventional coronary artery bypass surgery using CPB.

The role of donor age and ischemic time on survival following orthotopic heart transplantation.

BACKGROUND: The advances in immunotherapy, along with a liberalization of eligibility criteria have contributed significantly to the ever increasing demand for donor organs. In an attempt to expand the donor pool, transplant programs are now accepting older donors as well as donors from more remote areas. The purpose of this study is to determine the effect of donor age and organ ischemic time on survival following orthotopic heart transplantation (OHT). METHODS: From April 1981 to December 1996 372 adult patients underwent OHT at the University of Western Ontario. Cox proportional hazards models were used to identify predictors of outcome. Variables affecting survival were then entered into a stepwise logistic regression model to develop probability models for 30-day- and 1-year-mortality. RESULTS: The mean age of the recipient population was 45.6 +/- 12.3 years (range 18-64 years: 54 < or = 30; 237 were 31-55; 91 > 56 years). The majority (329 patients, 86.1%) were male and the most common indications for OHT were ischemic (n = 180) and idiopathic (n = 171) cardiomyopathy. Total ischemic time (TIT) was 202.4 +/- 84.5 minutes (range 47-457 minutes). In 86 donors TIT was under 2 hours while it was between 2 and 4 hours in 168, and more than 4 hours in 128 donors. Actuarial survival was 80%, 73%, and 55% at 1, 5, and 10 years respectively. By Cox proportional hazards models, recipient status (Status I-II vs III-IV; risk ratio 1.75; p = 0.003) and donor age, examined as either a continuous or categorical variable ([age < 35 vs > or = 35; risk ratio 1.98; p < 0.001], [age < 50 vs > or = 50; risk ratio 2.20; p < 0.001], [age < 35 vs 35-49 versus > or = 50; risk ratio 1.83; p < 0.001]), were the only predictors of operative mortality. In this analysis, total graft ischemic time had no effect on survival. However, using the Kaplan-Meier method followed by Mantel-Cox logrank analysis, ischemic time did have a significant effect on survival if donor age was > 50 years (p = 0.009). By stepwise logistic regression analysis, a probability model for survival was then developed based on donor age, the interaction between donor age and ischemic time, and patient status. CONCLUSIONS: Improvements in myocardial preservation and peri-operative management may allow for the safe utilization of donor organs with prolonged ischemic times. Older donors are associated with decreased peri-operative and long-term survival following. OHT, particularly if graft ischemic time exceeds 240 minutes and if these donor hearts are transplanted into urgent (Status III-IV) recipients.

Safety and cost-effectiveness of MIDCABG in high-risk CABG patients.

BACKGROUND: Myocardial revascularization without cardiopulmonary bypass has been proposed as a potential therapeutic alternative in high-risk patients undergoing coronary artery bypass grafting. To evaluate this possibility we compared 15 high-risk (HR) patients in whom minimally invasive direct coronary artery bypass grafting was used as the method of revascularization with 41 consecutive patients who underwent conventional coronary artery bypass grafting during 1 month. METHODS: Patients undergoing myocardial revascularization without cardiopulmonary bypass were significantly older than their low-risk (LR) counterparts (72.2 +/- 11.6 versus 63.3 +/- 9.7 years, p = 0.006). The demographic profile for HR versus LR patients was as follows: female patients, 60.0% versus 26.8%, p = 0.02; diabetes, 20.0% versus 24.4%, p = 0.7; prior stroke, 33.3% versus 7.4%, p = 0.03; chronic obstructive pulmonary disease, 60.0% versus 9.8%, p < 0.0001; peripheral vascular disease, 33.3% versus 12.2%, p = 0.03, congestive heart failure, 26.6% versus 9.8%, p = 0.09; impaired left ventricular (ejection fraction < 0.40), 40.0% versus 17.0%, p = 0.07; urgent operation, 86.6% versus 46.3%, p < 0.0001; and redo operation, 20.0% versus 0%, p = 0.003. RESULTS: There were no deaths in the HR group and one death in the LR group. The average intensive care unit stay was 1.1 +/- 0.5 days in HR patients versus 1.6 +/- 1.6 days in LR individuals (p = 0.2), and the average hospital stay was 6.1 +/- 1.8 versus 7.3 +/- 4.4 days, respectively (p = 0.3). We used an acuity risk score index developed by the Adult Cardiac Care Network of Ontario to predict outcome in the HR group. The expected intensive care unit stay in HR patients was 4.1 +/- 1.2 days (versus the observed stay of 1.1 +/- 0.5 days, p < 0.0001), and the expected hospital stay was 12.5 +/- 1.5 days (versus the observed stay of 6.1 +/- 1.8 days, p < 0.0001). The expected mortality in the HR group was 6.1% versus 0%, p = 0.3. A cost regression model was used to examine predicted versus actual cost (in Canadian dollars) for the HR patient cohort (based on Ontario Ministry of Health funding). The expected cost for the HR cohort would have been $11,997 per patient. In contrast, the average cost for these 15 patients was $5,997 per patient, an estimated cost saving of 50%. CONCLUSIONS: Myocardial revascularization without cardiopulmonary bypass appears to be a safe and cost-effective therapeutic modality for HR patients requiring myocardial revascularization.

Left anterior descending endarterectomy and internal thoracic artery bypass for diffuse coronary disease.

BACKGROUND: The risk and efficacy of using an arterial conduit to bypass an endarterectomized coronary artery remain incompletely defined. To address this question we analyzed retrospectively 74 patients from 1989 to 1994 in whom bypass grafting using the left internal thoracic artery to an endarterectomized left anterior descending artery was performed. METHODS: There were 60 men and 14 women with a mean age of 60.1 +/- 8.6 years. Of this cohort, 55 patients (74.3%) had a previous infarction, 18 (24.3%) were diabetic, and 5 (6.7%) had reoperations; 25 patients (34%) had a totally occluded left anterior descending artery and the average ejection fraction was 45%. Each patient had 2.95 +/- 0.52 grafts with 48 patients (65%) requiring multiple endarterectomies. The average length of the endarterectomized segment was 3.1 +/- 1.6 cm. Average anoxia time was 49 +/- 13 minutes. Postoperatively 19 patients (25.6%) required intraaortic balloon and 18 (24.3%) required inotropic support. Perioperative infarction in the left anterior descending artery distribution occurred in 5 patients (6.7%). RESULTS: There were 3 (4.0%) early and 4 (5.4%) late deaths at a mean follow-up of 36 +/- 16 months. Recurrent angina was present in 9 patients (14.7%). Actuarial 5-year survival was 84.5%. Angiographic follow-up obtained in 23 patients (37.4%) demonstrated 74% anastomotic patency, with good distal run-off in 13 (65%). The anterior segmental wall motion was preserved. CONCLUSIONS: The use of the left internal thoracic artery bypass and adjunctive left anterior descending artery endarterectomy to expand the scope of myocardial revascularization in carefully selected circumstances appears to be beneficial.

The pupillary response to light in the turtle.

When intense adapting lights are turned off, the pupil of the turtle, Pseudemys scripta elegans, enlarges. The recovery functions for pupillary dilation have different time constants that are defined by red- and green-sensitive cones and rods as they are affected by prior light adaptation and time in the dark. Pupillary area related to dilation responds over at least a three- to four-fold range. Following white-light adaptation, the course of pupil dilation in the dark shows a three-legged curve of differing time constants. With spectral-light adaptations, the contributions of separate classes of photoreceptors can be isolated. Red- and green-sensitive cones contribute shorter time constants of 3.31 and 3.65 min to prior white-light adaptation--4.81 and 4.18 min to prior spectral-light adaptations. Rods contribute a much longer time constant of 6.69 min to prior white-light adaptation--7.60 min to prior spectral-light adaptation. The ratios are in keeping with the flash sensitivities of photoreceptors in this same animal, as well as with psychophysical visual threshold mechanisms of color sensitivity.