Surgical Technology International
42nd Edition
September 2023 - ISSN:1090-3941
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Aortic Annuloplasty: Focus on the Use of an External Teflon Ring
IIlaria Chirichilli, MD, Francesco Irace, MD, A. O. San Camillo, Forlanini, Rome, Italy , Alessandro Ricci, MD, Luca Weltert, MD, Professor , Mario Torre, MD, Raffaele Scaffa, MD, Giulio Folino, MD, Andrea Salica, MD, Salvatore D’Aleo, MD, Lorenzo Guerrieri Wolf, MD, Samuel Fusca, MD, Alessandro Bellisario, MD, Giulia Marra, MD, Marco Andreis, MD, Camilla Ciani, MD, Sara Forcina, MD, Ruggero De Paulis, MD, Professor , European Hospital, Rome, Italy
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Aortic annuloplasty has been clearly demonstrated to have a protective influence in aortic valve repair. Over the past 20 years, different annuloplasty concepts have been proposed by different groups. However, the most appropriate approach to enable long-term annular stability remains highly controversial. The aim of this article is to give a general overview of all types of aortic annuloplasty, particularly focusing on the use of an external Teflon ring, as proposed by our group. In this technique, external root dissection is performed in the same fashion as for reimplantation; the only difference is that it is necessary to go below the coronary ostia take-off. A series of pledgeted sutures (usually between 6 and 9 sutures) are placed at the level of the virtual basal ring. The external ring is made using a Teflon strip with a length of 8 to 9 cm, to reduce the annulus to a diameter of between 21 and 23 mm. The sub-annular sutures are then passed at the appropriate level through the Teflon strip and the strip is parachuted outside the aortic root base, passing under the coronary ostia. The two ends of the Teflon strip are tied at the level of the non-coronary sinus. Aortic annuloplasty is a crucial step to improve valve competence and stabilization. While several techniques offer good mid- to long-term results, annuloplasty with an external Teflon ring appears to be a simple and effective alternative to guarantee stable root diameters. Longer follow-up studies are needed to confirm the mid- to long-term results.
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Negative Pressure Wound Therapy: Comparison of Outpatient and Inpatient Approaches
Giuseppe Santarpino, MD, Giuseppe Nasso, MD, Giuseppe Speziale, MD, Anthea Hospital, GVM Care & Research, Bari, Italy, Ignazio Condello, PhD , GVM Care & Research, Perfusion Service, Anthea Hospital, Bari, Italy
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Background: The results of recent studies regarding the efficacy of Negative Pressure Wound Therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery are not conclusive.
Methods: Data were collected from patients who were operated upon at the GVM Care & Research group in Italy from 2013 to 2021; all patients who required treatment for sternotomy wound infection with Negative Pressure Wound Therapy (NPWT) through WaterLily™ system (Eurosets, Medolla, MO, Italy) were selected. We compared the preoperative risk characteristics, and particularly those that were most strongly associated with possible dehiscence of the wound. A statistical analysis was performed for comparison of the groups.
Results: Out of the total 40,267 patients who underwent cardiac surgery with extracorporeal circulation within this time frame, 1,483 (3.68%) required NPWT, including 690 (46.52%) in the HOME group and 793 (53.47%) in the HOSPITAL group (p =0.76). Thirty-nine (5.65%) patients in the HOME group and 37 (4.66%) in the HOSPITAL group required re-treatment for re-dehiscence after secondary closure (p =0.79).
Conclusions: The use of a WaterLily™ system (Eurosets, Medolla, MO, Italy) was safe and effective for the treatment of sternotomy wounds with superficial and deep infections and was associated with a low rate of dehiscence, even when used with discharged and managed outpatient patients.
Thyroglossal Duct Cyst Mimicking a Hygroma Colli – An Unusual Presentation
Lieke Dullens , Henri Decloedt, Faculty of Medicine, UZ Leuven, Belgium , Jan F Gielis, MD, PhD, Joren Callaert, MD, Koen Deloose, MD, AZ Sint Blasius, Dendermonde, Belgium
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A thyroglossal duct cyst (TGDC) is the result of incomplete degeneration of the thyroglossal duct during gestation. It is the most common type of congenital cyst of the neck, and is usually seen in children. The tumor mostly appears at the midline of the neck and generally causes no symptoms, but the mass typically moves when the patient swallows. We present the unusual case of a 50-year-old man with a large cervical mass lateralized on the right side of the neck. There was no association between swallowing and movement of the mass. Clinical examination and computed tomography (CT) suggested a lymphangioma or cystic hygroma. Surgical resection showed a large cyst of 71 x 40 x 52 mm with no attachment to the hyoid bone and no invasion in blood vessels or other surrounding tissue. Histopathological investigation led to a diagnosis of TGDC.
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Detachable Aortic Clamp for Minimally Invasive Cardiac Surgery
Bleri Celmeta, MD, Tommaso Viva, MD, Arturo Bisogno, MD, Vito Domenico Bruno, MD, PhD, Antonio Miceli, MD, PhD, Mattia Glauber, MD, IRCCS Ospedale Galeazzi – Sant’Ambrogio, Minimally Invasive Cardiac Surgery Unit, Milan Italy
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Since its first implementation, minimally invasive cardiac surgery has become more and more popular among surgeons. By avoiding a complete opening of the sternum, this surgery is traditionally associated with a faster recovery, less surgical pain and less postoperative bleeding and transfusions. With its growing popularity, the need for specifically designed surgical instrumentation is evident.
Since 2008, the detachable-branch Glauber clamp (Cardiovision-Trytech, Tokyo, Japan) has been used to facilitate aortic cross-clamp during minimally invasive cardiac surgery, to optimize the intraoperative visualization field without the need for adjunctive incisions of the thorax. It has been specifically developed for limited single-access minimally invasive valve surgery. The clamp is introduced through the main access incision (mini-sternotomy or mini thoracotomy) by means of a specifically designed delivery system, which is subsequently removed, leaving inside the thorax only the detachable closed branches on the aorta. Since its first implementation, the clamp has been used in numerous patients at several cardiac surgery centers worldwide. Over the years, attempts have been made to improve its ergonomics and enhance its performance. The G2 detachable-branch Glauber clamp (USB Medical, Hatboro, PA, USA) occupies a smaller space inside the thorax, has a simplified gripping mechanism and comes with detachable arms that enhance versatility with up to 10 possible clamp configurations. This article describes the characteristics of detachable-branch aortic clamps and compares them to other aortic cross-clamps that are currently available for minimally invasive cardiac surgery.
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Evaluation of (Wet) and (Dry) Mediastinal Chest Drainage in Minimally Invasive and Conventional Cardiac Surgery
Ignazio Condello, PhD, Giuseppe Nasso, MD, Flavio Fiore, MD, Giuseppe Speziale, MD, GVM Care & Research, Cardiac Surgery, Anthea Hospital, Bari, Italy
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Background: Drainage of fluid and evacuation of air from the pericardial and pleural spaces after cardiothoracic surgery is necessary to prevent effusion, tamponade, and pneumothorax, and also to detect hemorrhage. For this purpose, negative-pressure drains are placed in the mediastinum and pleural cavities. We compared the efficacy and safety of two systems wet and dry drainage for the management and monitoring of negative pressure and anti-reflux valve safety systems, to promote healing of the pleural and pericardial cavities.
Methods: Two devices for mediastinal chest drainage [Venice PAS (Wet) and Rome PAS (Dry); both Eurosets SRL, Medolla, Italy] were evaluated in terms of safety, efficacy and clinical outcomes in a cohort of 60 patients who underwent elective cardiac surgery procedures. The patients were divided into a minimally invasive cardiac surgery (MICS) group [n=30; mitral valve surgery (MVS) by right anterolateral mini-thoracotomy] and a conventional cardiac surgery (CCS) group [n=30; coronary arterial bypass grafting (CABG) in full sternotomy] at a single institution (Anthea Hospital GVM Care & Research, Bari, Italy).
Results: Negative pressure was managed with a target value of -20 cmH2O measured in the chest tube and was related to the device: deviation of ± 1 cmH2O for the Venice PAS (Wet) and 0 cmH2O for the Rome PAS (Dry) in the MICS group; deviation of 1 ± 0.8 cmH2O for the Venice PAS (Wet) and 0.8±0.2 cmH2O for the Rome PAS (Dry) in the CCS group. A constant volumetric air leak meter (VALM) value and the absence of air-leak bubbling were correlated with the absence of air in the pleural cavity and complete pulmonary re-expansion to restore normal respiratory dynamics in the MICS group for both models of chest drainage. The maximum total pericardial blood drained was 1104 ± 302 ml with Venice PAS (Wet) and 1530 ± 230 with Rome PAS (Dry) in the CCS group. There were no reports of cardiac tamponade in either group.
Conclusions: The two mediastinal chest drainage devices [Venice PAS (Wet) and Rome PAS (Dry)] in this study were effective, accurate for measuring the applied negative pressure, and safe in their application after cardiac surgery procedures via minimally invasive and conventional approaches for blood and liquid drainage, prevention of cardiac tamponade, and restoration of normal respiratory dynamics after surgical pneumothorax. Both systems are equipped with anti-reflux valves to prevent air and blood from entering the drainage, and no adverse events were reported.
The Venous Thrombectomy Armamentarium: An Expanding World
Jason Storch, BA, Justin M. George, MD, Christopher Hatzis, MD, Jonathan Lee, MD, Ajit Rao, MD, Windsor Ting, MD, Professor, Michael L. Marin, MD, Professor, Peter Faries, MD, Professor, Rami O. Tadros, MD, Professor, Division of Vascular Surgery, Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Acute deep venous thrombosis (DVT) is a common and important public health problem. It affects more than 350,000 people in the United States annually and has a substantial economic impact. Without adequate treatment, there is significant risk of development of post-thrombotic syndrome (PTS) resulting in patient morbidity, worse quality of life, and costly long-term medical care. Over the past decade, the treatment algorithm for patients with acute DVT has significantly changed. Prior to 2008, the treatment recommendation for patients with acute DVT was limited to anticoagulation and conservative management. In 2008, national clinical practice guidelines were updated to include interventional strategies such as surgical- and catheter-based techniques for the treatment of acute DVT. Early strategies for debulking of extensive acute DVT primarily consisted of open surgical thrombectomy and administration of thrombolytics. In the intervening period, a plethora of advanced endovascular techniques and technologies have been developed which reduced the morbidity of operative intervention and risks of hemorrhage associated with thrombolysis. This review will focus on the novel technologies commercially available for management of acute DVT, denoting unique features inherent to each device. This expanded armamentarium gives vascular surgeons and proceduralists the opportunity to individualize their treatment approach to the specific patient’s anatomy, lesion, and history.
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Clinical Evaluation of the Eurosets Trilly Oxygenator During Cardiopulmonary Bypass in a Pediatric Population
Simona Tani, MD , Marco Pesce, MD, Giuseppe Squillaci, MD, Martina Fontana, MD, Francesco Santoro, MD, IRCCS Istituto Giannina Gaslini, Genova, Italy , Andrea Dato, MD, Maria Mininni MD, IRCCS Istituto Giannina Gaslini, Genova, Italy, Ignazio Condello, PhD, Elena Ribera, MD, Anthea Hospital, GVM Care & Research, Bari, Italy, Maria Grazia Calevo, MD, IRCCS Istituto Giannina Gaslini, Genova, Italy
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The equipment selected for cardiopulmonary bypass (CPB) in pediatric cardiac surgery critically influences the safety, efficiency, efficacy and pathophysiological impact in perioperative use and the post-operative outcome. In this report, we present a single-center retrospective analysis of the clinical efficacy, efficiency and safety of the Trilly oxygenator (Eurosets Srl, Medolla, MO, Italy), which has an integrated arterial filter. It has a blood flow capacity of 500 to 3500ml/min, an AAMI index of 4.000ml / min, and a static fill prime (oxygenating module + heat exchanger) of 130 ml. We used this device on 42 pediatric patients who underwent repair of various congenital heart defects with cardiopulmonary bypass. Pre- and intraoperative patient data were collected for the evaluation of gas transfer and metabolic parameters in relation to blood flow, temperature and hematologic profiles.
The mean age of the patients was 8.07 ± 2.9 years. Eight patients had cyanotic heart disease, 7 had chromosomal abnormalities and 9 had previously undergone cardiac surgery. The STAT Mortality Category Score was distributed as follows: Cat. 1 (37.5%), Cat. 2 (35%), Cat. 3 (5%), Cat. 4 (22.5%), Cat. 5 (0%). The mean bodyweight was 29.03 ± 8.25 kg and the blood flow rate was 2664.88 ± 508.43 ml / min. The mean cardiopulmonary bypass time was 95±51.4 min and the cross-clamp time was 37±34.6 min. The mean gas transfer values were as follows: partial pressure of oxygen, post oxygenator, 224.7±28 mmHg; partial pressure of carbon dioxide, post oxygenator, 42±4 mmHg; oxygen delivery 356.9± 88.8 ml/min/m2; carbon dioxide transfer, 52.81± 1.98 mmHg, mixed venous saturation 77.78 %; and mean hematocrit value 29.0±4 %.
The Trilly oxygenator was effective in terms of oxygen uptake, carbon dioxide removal, and heat exchange in a pediatric population undergoing cardiopulmonary bypass. This retrospective analysis showed that the Trilly is both safe and effective in clinical practice without iatrogenic problems.
Novel Bronchoscopic Management of Bronchopleural Fistula Following Pneumonectomy
Christopher Manley MD, DAABIP, Associate Professor, Nicole Kail, RRT, Stacey Su, MD, FACS, Associate Professor, Temple University Health System, Philadelphia, Pennsylvania
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Bronchopleural fistula (BPF) is a rare but significant cause of morbidity and mortality in cancer patients undergoing surgical lung resection. The mainstay of treatment for BPF is revision of surgical stump. We describe a case of persistent bronchopleural fistula treated with a novel combination of argon plasma coagulation and fibrin glue.
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