Median Incision Research Articles

Analysis of sternal healing after median sternotomy in low risk patients at midterm follow-up: retrospective cohort study from two centres

BackgroundFor low risk patients undergoing median sternotomies, no midterm follow-up studies involving sternal healing have been conducted. In this study we evaluated sternal healing in low risk patients by chest CT scan and the risk factors associated with poor healing were analyzed.MethodsPatients who underwent sternal median incision heart surgery from September 2014 to March 2015 were recruited. The clinical information of these patients during hospitalization was collected, and the CT scan data were submitted to the two chief physicians of the Radiology Department for radiographical sternal healing score determination. Based on the method of wound closure, the patients were divided into sternum plate (Plates) and wire groups (Wires).ResultsForty-four patients were recruited. The mean CT examination time was 17.27 ± 2.30 months postoperatively. Twenty-nine (65.9%) patients met the criteria for radiographic sternal healing. Three segments, including the aortopulmonary window, the main pulmonary artery, and the aortic root, had healed less in comparison to the manubrium segment. Compared to patients in whom 6–7 metal wires were used for sternal closure, healing of the lower sternum was worse in patients in whom five wires were used, but the difference in healing was not statistically significant. Univariate analysis of sternal healing showed that patient age was a risk factor for sternal non-healing. When the patient age was > 45 years, the predicted risk of radiographic sternal non-union was 1.833 (95% CI: 1.343–2.503).ConclusionsAt the mid-term follow-up, 65.9% of patients undergoing median sternotomies demonstrated radiographic sternal healing. Age, but not closure device, was a risk factor for sternal non-healing in low risk patients. Use of more wires had a positive impact on sternal healing.Trial registrationresearchregistry4918, registered 28 May 2019, retrospectively registered.

EVOLUTIVE PECULIARITIES OF AN ILEO-CECAL VALVE TUMOR: CASE REPORT

Introduction: Tumors of ileo-caecal valve are most clinically manifested either through transit disorders or anemic syndrome.
 The 88-year-old patient is admitted for abdominal pain in the left flank, vomiting, asthenia and lack of intestinal transit for faeces, with a progressive onset of one week. Clinical examination: generalized affected state, wide abdomen, painful left flank and hypochondrium, lack of intestinal transit and pallor. Paraclinic: severe hypochromic microchrome anemia (hemoglobin: 5.8 g / dl). Plain radiography: hydro-aeric levels in the left hypochondrium. Abdominal CT: ileo-colic intussusception that completely occupies the ascending colon to the hepatic flexure, with no visible tumoral lesions. After hydroelectrolytic and hemodynamic balancing with restoration of intestinal transit, colonoscopy is performed: 5 cm ulcer-vegetative tumor formation at the ileo-caecal valve level - biopsy with histopathological examination: moderately differentiated adenocarcinoma. Patient refuses surgery.
 After 3 weeks, the patient returns to the clinic for the recurrence of digestive symptoms and emergency surgery is performed: laparotomy by median suprasubombilical incision, finding: ileo-ceco-appendico-colic invagination up to the middle third of the transverse colon, defective attachment of ascending colon, ileum dilated with thick wall. The invagination is reduced, the tumor formation is discovered. Right hemicolectomy with ileotransversoanastomosis is performed. Postoperatively, the patient shows a simple evolution with discharge of the 9th postoperative day.
 Conclusions: The ileocolic invagination in adults is most often the appearance of a tumor located on mobile segments of the intestine. The right colon invagination is possible when there is a defect of acolation, anatomical peculiarity encountered in the presented case.

2122 5mm Mini Single Hole Incision Laparoscopic Hysterectomy: Series of Five Cases

Study Objective To investigate the feasibility and safety of single-port laparoscopic hysterectomy with 5mm mini incision. Design The clinical data of 5 patients who underwent 5mm mini-incision single-port laparoscopic hysterectomy were retrospectively analyzed. Setting Department of Obstetrics and Gynecology, C the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University. Patients or Participants 5 patients who underwent 5mm mini-incision single-port laparoscopic hysterectomy. Interventions The median longitudinal incision of the umbilicus is about 5mm long, and the subcutaneous sneak expansion space is 3-5mm. The 40/50 small abdominal retractor expands and retracts the incision approach, using small lenses such as pediatric surgical laparoscopy, cystoscopy or hysteroscopy. Place the operating instrument to perform the operation. Measurements and Main Results Five patients in this group were successfully operated. No other channels were added during the operation, and no laparotomy was performed. The operation time is 100-195 min, in which the puncture establishes the surgical access part for 5-10 min, and the umbilical hole reconstruction part 3-5 min; The intraoperative blood loss was 50-100 ml, the body temperature was 36.5°C to 37.5°C after 1 day, and the anus exhaust time was 1.0-1.5 days. The patient was discharged from hospital for 6-7 days. The postoperative umbilical wounds healed well, almost no surgical scars were seen, and no postoperative umbilical hernia and other serious complications occurred. Conclusion Under the premise of mature laparoscopic technique, it is safe and effective to perform a 5mm mini incision laparoscopic hysterectomy.

The safety of esophagojejunostomy via a transorally inserted-anvil method vs extracorporeal anastomosis using a circular stapler during total gastrectomy for Siewert type 2 adenocarcinoma of the esophagogastric junction.

BackgroundIntracorporeal esophagojejunostomy via a transorally inserted-anvil method during laparoscopic total gastrectomy (LTG) for upper gastric cancer has been demonstrated to be feasible, but the use of this assessment exclusively for Siewert type 2 adenocarcinoma of the esophagogastric junction (AEG) has not been reported.MethodsA total of 428 consecutive gastric-cancer patients who underwent LTG in Nanfang Hospital from January 2008 to December 2016 were reviewed. Among these patients, 98 were classified as Siewert type 2 AEG. The patients underwent intracorporeal esophagojejunostomy through either a transorally inserted-anvil method (n = 27) or extracorporeal anastomosis usinga circular stapler (n = 71). After generating propensity scores with covariates that were associated with developing anastomotic leakage, 26 patients who underwent esophagojejunostomy via the transorally inserted-anvil method (transoral group) were 1:1 matched with 26 patients who underwent the procedure via extracorporeal anastomosis using a circular stapler (extracorporeal group). The safety after 30 days post-operatively was compared between the two groups.ResultsThe transoral group and extracorporeal group were balanced regarding the baseline variables. The operative time, reconstruction duration, number of dissected lymph nodes, length of the proximal resection margins, estimated blood loss, intra-operative complication rate, and post-operative recovery course were not significantly different between the two groups. The mean anvil-insertion completion time (9.7 ± 3.0 vs 13.4 ± 2.0 minutes, P < 0.001) and the median incision length (5.5 vs 7.0 cm, P < 0.001) in the transoral group were shorter than those in the extracorporeal group. The incidence of post-operative complications (26.9% vs 23.1%, P = 0.749) and the classification of complication severity (P = 0.939) were similar between the two groups.ConclusionsIntracorporeal esophagojejunostomy through a transorally inserted-anvil method may be a potentially safe approach to simplify and optimize the procedure during LTG for Siewert type 2 AEG.

EP1.15-14 Mediastinal Lymph Node Dissection Through Median Sternotomy in Thyroid Carcinoma

Recurrent cervical and mediastinal lymph node metastasis after the surgery of thyroid carcinoma is frequently reported. Generally, surgery is the best treatment but there is still no established standard surgical procedure. In our hospital, we perform the operation through median sternotomy. Surgical procedure for recurrent cervical and mediastinal lymph node metastasis after thyroid carcinoma varies throughout each institute. Recently, reports of the usage of VATs in these cases are increasing. We report 2 resected cases of cervical and mediastinal lymph node metastasis after thyroid cancer which underwent dissection through median sternotomy. A 68-year-old Japanese man underwent left thyroid lobectomy for poorly differentiated thyroid cancer in September 2009. The follow-up CT in 2014 showed a multiple mediastinal lymph node metastases. Therefore, the patient underwent mediastinal lymph node dissection through median sternotomy. Pathological findings showed metastasis in 24 of the 42 lymph nodes. During outpatient follow-up, CT revealed a recurrent mass lesion in the vincinity of the right subclavian artery and common carotid artery. Although I131 was administered, the mass did not respond. Therefore surgery therapy was required. The second operation was cervical incision. The pathological findings showed consistent recurrence. The patient was discharged from the hospital on postoperative day 4. The second patient was a 58-year-old Japanese man who had been treated by subtotal thyroidectomy in May 2008. The patient noticed a gradual increase of a mass near his right lower jaw from 2011. As a result of further examination, mediastinal lymph node metastasis was suspected. The patient underwent mediastinal lymph node dissection through median sternotomy and neck collar incision. Pathological findings showed metastasis in 9 of the 31 lymph nodes. Pathological findings revealed metastasis of papillary thyroid carcinoma. The patient was discharged from the hospital on postoperative day 13. Recent reports of recurrent cervical and mediastinal lymph node metastasis after thyroid carcinoma suggests using VATs, which may have less complications. In our hospital, the possibility of micrometastases is also considered in cases of post-operative lymph node recurrence. Therefore, we completely resect the mediastinal lymph nodes by median sternotomy approach. We have been promoting mediastinal lymph node dissection for lung cancer surgery at our center, but we would like to report the significance of mediastinal lymph node dissection for recurrence cases after thyroid carcinoma.

2266 Simultaneous Coronary Artery Bypass Grafting and Orthotopic Liver Transplantation

INTRODUCTION: Patients with Decompensated Cirrhosis requiring Coronary artery bypass grafting (CABG) before liver transplantation are at significant risk of liver failure and death. We discuss a simultaneous CABG and liver transplantation approach to offer the best therapeutic option in such cases. CASE DESCRIPTION/METHODS: Our patient is a 56-year-old male with decompensated cirrhosis related to Ethanol and Fatty liver. He had severe coronary artery disease of the proximal, mid and distal Right coronary artery (RCA) not amenable to PCI. Once a donor liver allograft was found to be suitable, simultaneous CABG with liver transplantation was performed. Initially after procuring the saphenous vein from the right leg, a median sternotomy incision was performed and the pericardium was opened. Single vessel CABG to RCA was performed using the Saphenous vein graft off cardiopulmonary bypass. Chest was left open for the liver transplantation surgery. A bilateral subcostal incision with midline extension was performed. After explantation of the native liver, donor liver implantation was performed in a piggyback fashion where the venocavoplasty formed using middle and left hepatic vein of the recipient was anastomosed with the donor IVC. Venovenous bypass was not used. A Choledochocholedochostomy was performed. There were no major perioperative complications. A month after surgery, he has normal liver function and is recovering at home. DISCUSSION: In advanced liver disease patients needing liver transplantation and with concurrent CAD not amenable to PCI, it is not always possible to perform staged surgeries. In our case the anticipated morbidity and mortality rate was high with either surgery performed alone. Our patient’s probability of post operative mortality one year after major surgery according to the Mayo Clinic risk calculator was 32%. Recipient hepatectomy during liver transplantation in the background of severe CAD and with already reduced systemic pressure could result in major hemodynamic instability and acute coronary ischemia. He underwent simultaneous CABG and liver transplantation successfully. Survival rates of 80% have been reported in case series from more than a decade ago (Table 1). All patients should have preserved ventricular function. Simultaneous CABG and liver transplantation can offer the best therapeutic option with good perioperative and long term survival rate for patients with advanced liver disease who have severe CAD not amenable to PCI.

Self-Completion Method of Endoscopic Submucosal Dissection Using Endosaber without Any Other Device or Assistance: An ex vivo Porcine Model Study

Background: Endoscopic submucosal dissection (ESD) is a standard treatment for tumors of the gastrointestinal tract. We developed a self-completion method of ESD using Endosaber to eliminate the need for an additional device or human assistance during the procedure. The aim of this study was to evaluate the technical feasibility and outcomes of this method in an ex vivo porcine training model. Methods: This was a pilot study, and the procedures were performed by 4 experts. Mock lesions measuring 15 mm in diameter were prepared at the posterior wall in the middle or lower esophagus obtained from domestic pigs. Each operator performed ESD on the mock lesions in 3 models. The primary outcome was ESD completion rate using the self-completion method. The secondary outcomes were procedure time, en bloc resection rate, perforation rate, and number of injections during the procedure. Results: All 12 ESDs were completed using the self-completion method. The median procedure time (interquartile range) was 483.5 (399–619.3) s (median incision time: 240.4 [168.3–332.5] s; median dissection time: 222 [182.8–257] s). En bloc resection rate was 100%. No perforation was noted during any of the procedures. The median number of injections was 10.5 (9–14.3). The procedure time decreased significantly with increase in experience (p = 0.020). Conclusions: The self-completion ESD method using one Endosaber without any assistance achieved a 100% en bloc resection rate without any perforation. The need for an additional device or assistance was successfully eliminated. This method may prove to be a simple and cost-effective ESD procedure for lesions in humans.

A novel technique for removing large gastric subepithelial tumors with ESD method in the subcardia region.

Previously, patients with tumors larger than 4 cm in sub-cardia region usually received open gastrectomy. Due to its anatomic features, the cardia is often considered as a contraindicated area for endoscopic resection. Herein, we report a novel technique of endoscopic submucosal dissection (ESD) which facilitates the removal of gastric subepithelial tumors (SMTs) larger than 4 cm in the subcardia and fundus region. This is a retrospective case series of patients with SMTs larger than 4 cm in the subcardia and fundus regions who received the novel procedure of ESD between October 2015 and October 2016. The novel procedure of ESD involved a median linear incision of the mucosa being made in the central area of the tumor, followed by the submucosal dissection. The residual defect was finally closed using titanium endoclips. The endoscopical outcomes, histopathological findings as well as other complications were assessed. Eight patients fulfilled the entry criteria. The mean lesion size was 45.6±7.5 mm (range: 40.0–65.0 mm), and the mean operating time was 83±13 min (range: 60–100 min). The en bloc resection rate was 100%. Although perforations occurred in 5 out of 8 patients, they were successfully closed with endoclips. The median length of inpatient hospital stay was 6 days (range: 5–8 days). No patients needed further gastrectomy. The median follow-up was 36 months and none of the patients developed local recurrence or distant metastasis. The advanced procedure of ESD is feasible and safe for tumors more than 4 cm in the subcardia region. It could be applied as a novel technique for treating patient without surgical interventions.

Surgical treatment for Kommerell's diverticulum associated with aortic dissection involving aortic arch.

Kommerell diverticulum with aortic dissection involving aortic arch is a rare but troublesome condition. The purpose of this study is to summarize the experience and strategy of surgical treatment. From November 2015 to January 2018, seven consecutive patients underwent surgical treatment in our institution. Three patients with acute type A aortic dissection and one patient with acute type B aortic dissection received total arch replacement and frozen elephant trunk (FET) implantation through median sternotomy. Three patients with chronic type B aortic dissection underwent total aortic arch and descending aorta replacement through median sternotomy and lateral thoracotomy. There were seven male patients whose median age was 42.3 ± 11.7 (from 14 to 54) years old. There was no perioperative death in this study. One patient had postoperative critical illness polyneuropathy and required prolonged mechanical ventilation (485 hours) and recovered finally. Follow up was completed for all seven patients with a median follow-up time of 7 (3-46) months. One patient with type A dissection developed aneurysm of the descending aorta distal to the FET and received reintervention. No clinical events and abnormal computed tomography manifestations were found in the other seven patients. Total arch replacement and FET through single median incision is a reliable method for Kommerell diverticulum associated with acute dissection involving arch. For Kommerell diverticulum associated with chronic type A or B aortic dissection involving aortic arch, graft replacement by double or single incision is safe and appropriate.

Human cadaveric model for studying the preservation of mental nerve during transoral endoscopic thyroidectomy.

Mental nerve (MN) injury can be caused by transoral endoscopic thyroidectomy vestibular approach (TOETVA). The purpose of this experimental study was to determine the location and distribution pattern of MN structures in relation to oral vestibular incisions. Ten cadaver specimens were included, yielding a total of 20 MNs. The difference between standard 10-mm TOETVA median incision and modified incision (i.e. lower and perpendicular) was compared. All 20 MNs were successfully dissected and presented as bifid (100%), lateral toward medial direction. The branches of MNs were equally distributed into both right and left sides. Standard lateral 5-mm vestibular incisions did not determine any division of MN branches. Two left MNs (25%) and one right MN (12.5%) were injured by standard median vestibular incision. Using a more inferiorly positioned and a vertical median incision, the integrity of MN branches was preserved. Standard lateral 5-mm vestibular incisions are safe for determining MN integrity. The 10-mm median vestibular incision divided the medial ramifications of MN at a rate of 12-25%. These may result in MN ipsilateral or bilateral paralysis. Hence, it is recommended to locate the median incision more inferiorly or vertically.

Through Tricuspid Closure for Doubly Committed Subarterial Ventricular Septal Defect with Right Vertical Subaxillary Mini-incision: A Matched-Pair Analysis.

To evaluate the feasibility and efficacy of the right subaxillary vertical mini-incision (RAVI) used for the closure of doubly committed subarterial ventricular septal defect (SAVSD) through tricuspid approach only. From June 2015 to September 2016, 32 SAVSD patients (mean age 2.4 ± 1.9years, range 0.7-8years) underwent surgical repair with either RAVI (incision length 3-4cm) through tricuspid (group A, n = 16) or conventional median sternotomy incision through the main pulmonary artery approach (group B, n = 16). A retrospective 1:1 matched-pair analysis was performed with the group B matched for defect size, body weight, gender, patching, and operation year. The demographic characteristics in both groups were similar. No patient died and only 1 patient in group B needed reoperation for sternal infection. The mean cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 48.6 ± 12.6min, 29.3 ± 8.5min in the group A and 57.8 ± 14.1min (p = 0.03), 34.3 ± 12.1min ( p = 0.18) in the group B. There was no significant difference between the two groups in the ICU stay (17.8 ± 8.9h in group A, 18.7 ± 9.5h in group B, p = 0.79), mechanical ventilation support time (2.7 ± 1.7h in group A, 3.6 ± 1.5h in group B, p = 0.11), postoperative hospital stay (6.3 ± 1.5days in group A, 7.4 ± 1.7days in group B, p = 0.06), and chest tube drainage (6.4 ± 4.3ml/kg in group A, 8.5 ± 3.8ml/kg in group B, p = 0.16). No significant residual defects were found in both groups. The post-operation pressure gradient across the right ventricular outflow tract (RVOT) was significantly different between the two groups with 4.6 ± 1.8mmHg in group A and 10.0 ± 6.8mmHg in group B (p = 0.004) even if no significant difference was found between both groups before operation. No arrhythmia was found after operation. All the patients or the parents (100%) in the group A were satisfied with the cosmetic results, while the number in B group was 7 (43.8%) in questionnaire. The RAVI through tricuspid approach to repair doubly committed subarterial ventricular septal defect is a safe and feasible procedure with better hemodynamic performance of RVOT and less CPB time because of keeping pulmonary artery intact comparing to conventional approach. More importantly, the RAVI through tricuspid approach can be performed with favorable cosmetic results.

Can proliferative hypertrophic scars of the median sternotomy incision predict the occurrence and characteristics of urethral stricture?

Objectives:To investigate the correlation between the characteristics of urethral stricture and incision scars in patients with urethral stricture and median sternotomy incision.Methods:We identified 368 patients who had undergone internal urethrotomy between January 2014 and December 2017. A total of 49 male patients with a median sternotomy scar and diagnosed with urethral stricture were retrospectively evaluated. The median sternotomy incision scars were assessed using the Vancouver Scar Scale (VSS) and the patients were divided into 2 groups. Group I consisted of patients with a VSS score of <4 points, and those with ≥4 points constituted group II. The groups were compared in terms of age, smoking habit, body mass index, diabetes mellitus, hypertension, urethral stricture etiology, length and localization, and stricture relapse after intervention.Results:The mean total VSS score was 2.0 points in group I and 7.46 points in group II. There was a significant correlation between the VSS total score and the urethral stricture length among the whole study population (correlation coefficient value=0.481; p<0.001). The urethral stricture was longer as the VSS score increased.Conclusion:A poorly healed median sternotomy incision scar can predict a poor wound healing in the urethra tissue. Further large scale, multi-center and prospective studies are needed to clarify this relationship.

SAT-133 A novel, phosphorescence-based technique to assess urinary oxygen tension

Renal hypoxia aggravates acute kidney injury and accelerates chronic kidney disease. Recently, the importance of urinary bladder oxygen tension, employed as a window of renal oxygen tension, has been shown in patients under cardiac surgery in the point that low urinary oxygen tension predicts postoperative acute kidney injury (Zhu MZL et al. Nephrol Dial Transplant 2018). However, measurement technique of urinary oxygen tension in murine is not established. Phosphorescence is a light which has unique character whose lifetime is inversely correlated to oxygen concentration, and we established oxygen tension measurement method at renal surface using phosphorescence (Hirakawa Y et al Sci Rep 2016, Hirakawa Y et al. Kidney Int 2018). This time we applied phosphorescence to urinary bladder oxygen tension measurement. The aim of this study is to establish a novel method to measure urinary oxygen tension, and to examine factors influencing urinary oxygen tension Balb/c mice were used in this research. A water-soluble small-molecule phosphorescent dye, BTP-PEG24, was administered via tail vein injection. Phosphorescence lifetime was measured by quantaurus-tau by Hamamatsu Photonics with two-branched optical fiber. Results of phosphorescence lifetime measurement were shown as mean ± standard deviation. Both of fluorescence stereoscopy and phosphorescence lifetime imaging microscopy revealed that this phosphorescent dye was rapidly excreted into urine and accumulated in the urinary bladder. Phosphorescence lifetime measurement was done after median incision in lower abdomen and placement of two-branched optical fiber near the urinary bladder. After BTP-PEG24 administration, phosphorescence lifetime was measured in normoxia, general hypoxia by 10% oxygen inhalation, and reoxygenation by return to room air inhalation, and phosphorescence lifetime changed from 2.18±0.15μs to 2.51±0.22μs (hypoxia) and 2.08±0.12μs (reoxygenation). The phosphorescence lifetime measurement could be done after the ligation of both ureters, and the value changed from 1.92±0.08μs to 2.11±0.17 (hypoxia) and 1.88±0.11μs (reoxygenation). Considering that shorter phosphorescence lifetime means higher oxygen tension, ligation of both ureters raised oxygen tension of bladder urine, which meant oxygen tension in pelvic urine was indeed affected by renal oxygenation. However, at least in part, the oxygen tension in pelvic urine was indicated to reflect the oxygen tension of bladder epithelia, since the phosphorescence lifetime changes according to oxygen concentration of inspired air. The results of phosphorescence lifetime measurement in urinary bladder with BTP-PEG24 were shown. Each “21%”, “10%”, and “Re21%” indicates normoxia, hypoxia, and reoxygenation, respectively. The dots with same color were obtained from the same mouse. N = 4 for sham group and N = 5 for ligation group. Each mouse underwent three phosphorescence lifetime measurements. We established novel technique to assess pelvic urine oxygen tension. Pelvic urine oxygen tension was shown to be influenced by both of oxygen tension in kidney and in bladder epithelia. Therefore, fresh urine, which might remain unaffected by bladder epithelia oxygenation, must be used as the window of renal oxygenation.

Primary Urachal Hydatid Cyst in a Child: A Case Report

The hydatid cyst (HC) is an endemic parasitic disease worldwide. Although the HC can locate in every part of a body, it rarely occurs over the abdominal wall. A 12-year-old female patient was brought to Department of Pediatric Surgery, Firat University School of Medicine, Elazig, Turkey in 2017. She had been suffering from abdominal pain for one week. A lump was determined underneath her skin in the suprapubic region. It was swollen, tense and movable. A cystic mass filling the midline was found in the radiological bladder superior. It was an anechoic cyst causing ondulation on the muscles of the anterior abdominal wall. The sizes of the mass were measured approximately as 9×7 cm (mesentery cyst?). The cystic mass was occurred in the urachal area of the anterior abdominal wall, not in the abdomen. After the cyst was emptied with applying mini median incision below the umbilicus, we saw the germinative membrane inside the cyst. Diagnosis of the HC was confirmed with the pathologic evaluation. For the differential diagnosis of a pure cystic mass, which can locate in every part of a body, diagnosis of the HC should be considered.

Efficacy of Total Aortic Arch Replacement Combined with Frozen Elephant Trunk in Aortic Reoperation.

BackgroundThe aim of this study was to estimate the long-term efficacy of total aortic arch replacement combined with the frozen elephant trunk (TAR+FET) technique for aortic disease following a prior cardiac surgery procedure.Material/MethodsWe performed TAR+FET for 118 patients for major vessel disease following a prior cardiac procedure with median sternotomy incision. All patients were divided into 5 groups: in group A, the prior major procedure was aortic valve replacement (AVR); in group B, the prior major procedure was isolated ascending aorta replacement; in group C, the prior major procedure was aortic root replacement; in group D, the prior major procedure was aortic arch replacement or intervention; and in group E, the prior major procedure was ‘other’ cardiac operative procedure. The long-term follow-up visit results were estimated using the Kaplan-Meier method.ResultsThe 30-day mortality rate after the operation was 13.6% (16/118) – 2 died in group A, 1 in group B, 8 in group C, 4 in group D, and 1 in group E. Follow-up visits were completed in 99% of patients. The mean follow-up time was 47.6±36.3 months and 12 patients had died by follow-up, so the total long-term survival rate was 76.3%. One-year survival rates of the 5 groups were 85% (group A), 93.8% (group B), 82.3% (group C), 50% (group D), and 50% (group E), respectively. Five-year survival rates of the 5 groups were 85%, 93.8%, 80.6%, 50%, and 50%, respectively.ConclusionsThe TAR+FET technique is feasible and efficacious for aortic reoperation in patients who previously underwent cardiac surgery since the short-term mortality in patients with recurrent aortic arch disease after cardiac surgery is not high.

Clinical Profile of Patients Undergoing Mass Closure and Layered Closure Techniques in Laparotomies

Background: Linen and Cotton were already in use. Silk was the next suture of choice in non-absorbable suture range. It became very popular because of its excellent handling properties. It was extensively used in all surgical procedures including Cardiovascular Surgery. Halstead was its main proponent. Thorough clinical examination of the patients was made and recorded. Particular attention was given to note the anaemia, nutritional status, jaundice, respiratory tract infections. Apart from the examination of the system involved, routine examination of CVS, RS &amp; CNS were carried out. Subjects and Methods: History taking was followed as a routine in all cases admitted to the wards.Plain X-ray abdomen, Contrast X-rays like barium meal, Upper GI endoscopy and Abdominal ultrasound and CT scan were done in necessary cases.However in emergency cases, only the investigations necessary for supporting the diagnosis were employed. Results: In this study mid line incision was done in 39 patients, 65% of patients, Right Para Median incision in 18 patients 30 %, left Para median in 3 patients, 5%. In this study in mass closure group a mean time taken (min) 15.73 was required for the closure of the incision with standard deviation of 1.82.In the layered closure group mean time taken (min) was 25.03 with a standard deviation of 1.83. Conclusion: The age of the patients ranged from 15-65 years. Out of 60 patients 16 were in the age group of &lt;30 years, 13 were 30-39 years, 11 were 40-49 years and 20 were &gt;50 years.

Application of Overlap anastomosis to Billroth I digestive tract reconstruction after laparoscopic distal gastrectomy in gastric cancer

Objective: To investigate the application value of Overlap anastomosis in Billroth I digestive tract reconstruction after laparoscopic distal gastrectomy in gastric cancer. Methods: Clinical data of 68 stage T1-2 gastric cancer patients undergoing laparoscopic distal gastrectomy for D2 radical gastrectomy from January 2015 to January 2016 at China Japan Union Hospital of Jilin University were retrospectively analyzed. Inclusion criteria: (1) no distant metastasis of gastric cancer confirmed by gastroscopy and pathology before surgery; (2) T1-2 tumor with diameter <3 cm; (3) the lesion locating in the antrum of the stomach with distance >1 cm from the pylorus, and no invasion into middle area; (4) R0 resection confirmed by postoperative pathology; (5) no history of abdominal surgery. Among 68 cases,23 cases were in Overlap anastomosis group and 45 cases in Billroth I anastomosis group. D2 lymph node dissection and distal gastrectomy were performed in both groups. In the Overlap anastomosis group, the duodenum and stomach were severed by a linear stapler under endoscopy, and the residual gastric curve anastomotic opening was selected. According to the tension between the duodenum and the remnant stomach, the anastomotic opening was selected at the upper edge of the remnant duodenum, and the anastomosis between the posterior wall of the remnant stomach and the upper wall of the duodenum was completed by placing the stapler under endoscopy. Then the common opening was closed and the remnant duodenum was resected. In the traditional Billroth I anastomosis group, pneumoperitoneum was discontinued after amputation of the duodenum under laparoscopy. The median incision of the upper abdomen was 9-12 cm. The distal stomach was pulled out to complete the excision of specimens, the extraction of specimens and Billroth I digestive tract reconstruction. The intraoperative and postoperative conditions of the two groups were compared with student t test (continuous variable) and chi-square test (categorica variable). Results: Of the 68 patients,39 were males and 29 were females,with age of (65.5±10.2)(51 to 77)years. Differences in baseline data between Overlap group and Billroth I group were not statistically significant (all P>0.05). Laparoscopic surgery was successfully performed in both groups without conversion to open operation. As compared with the Billroth I group, the Overlap group had significantly shorter operation time [(149.8±10.1) minutes vs. (169.8±15.3) minutes, t=5.658,P=0.008], shorter anastomotic time of digestive tract reconstruction [(31.2±3.8) minutes vs. (36.3±3.3) minutes, t=3.389, P=0.003] and shorter abdominal incision length [(4.5±0.9) cm vs.(11.0±2.3) cm, t=13.244,P=0.004]. There were no significant differences between two groups in intraoperative blood loss [(92.9±22.4) ml vs. (87.0±7.3) ml,t=1.186,P=0.366], number of lymph node dissected (28.4±5.7 vs. 27.3±5.2, t=0.838, P=0.383), postoperative flatus time [(4.4±2.1) days vs.(4.2±1.8) days, t=0.391, P=0.563], morbidity of postoperative complication [4.3%(1/23) vs. 6.7%(3/45), χ2=0.148,P=0.701]. All the patients were followed up for 28±10 (10-46) months. There were no long-term complications, recurrence or death in two groups. Conclusion: Overlap anastomosis in Billroth I digestive tract reconstruction after laparoscopic distal gastrectomy is safe and effective, and can reduce the anastomosis time.

Effect of bone marrow mesenchymal stromal cells and conditioned medium in an irreversible unilateral ureteral obstruction murine model.

Background & Aim In recent years, many studies have shown that bone marrow mesenchymal stromal cells (BM-MSCs) promote renal recovery and prevent renal damage. In an irreversible unilateral ureteral obstruction (UUO) model, less damage has been reported in rats treated with BM-MSCs after one or two weeks of administration. However, effects in the contralateral kidney had not been studied. The aim of this study is to evaluate the effect of BM-MSCs and CM in attenuating parenchymal damage in an irreversible unilateral ureteral obstruction model (obstructed and contralateral kidney). Methods, Results & Conclusion Methodology BM-MSCs were obtained by primary culture of bone marrow of male Wistar rats, characterized by flow cytometry (CD45-, CD90+, CD 29+) and then administered in passages 2 to 6. Female Wistar rats were divided in 4 groups for treatment under anesthesia and maximum asepsis: 1) Sham operated: median ventral incision and closure by planes (n=6); 2) UUO: Unilateral ureteral obstruction (n=6); 3) UUO + BM-MSC: Unilateral ureteral obstruction with immediate administration of 1 × 106 BM-MSC, by puncture of inferior vena cava (n=7) and 4) UUO + CM: Unilateral ureteral obstruction with immediate administration of 400 µl of conditioned medium (CM) by puncture of inferior vena cava (n=5). At 2 weeks, blood was extracted from the aorta to evaluate creatinine levels and both kidneys were excised. Semi-quantitative (PAS and H&E) and immunohistochemical (Alpha-smooth-muscle actin, E-cadherin and nitrotyrosine) scores were analyzed to evaluate epithelial-mesenchymal transition and nitro-oxidative injury. Statistical analysis was performed by using the t-tests and one way ANOVA with Tukey post hoc test as appropriate. A p-value of Results The administration of BM-MSC in a model of irreversible unilateral ureteral obstruction is associated with a lower creatinine level and less nitrooxidative injury in the contralateral kidney at day 14 (p Conclusion BM-MSC and CM could effectively preserve kidney function in an unilateral obstruction model by protecting the contralateral kidney against nitro-oxidative injury. These results suggest a potential clinical treatment for chronic kidney diseases. This nephroprotective effect can be attributed to the antioxidant and anti-inflammatory activities of BM-MSC and CM.

Video-assisted harvesting of internal thoracic artery through median sternotomy incision in pectus excavatum

Video-assisted harvesting of internal thoracic artery through median sternotomy incision in pectus excavatum

Early clinical outcomes of minimally invasive coronary surgery-total arterial coronary revascularization

Objective: To summarize the early experience and clinical value of minimally invasive coronary surgery-total arterial coronary revascularization (MICS-TACR) through the left anterior small incision. Methods: Between May 2015 and June 2018, a total of 31 consecutive cases [21 males and 10 females, aged (63.2±9.3) years] in Peking University Third Hospital who were performed MICS-TACR with bilateral internal mammary artery and radial artery were enrolled. Meanwhile, 1 489 cases of conventional median sternal incision off-pump coronary artery bypass grafting (OPCABG) were matched as control group. According to exclusion criteria and matching score, 90 cases [55 males and 35 females, aged (63.8±9.5) years] were selected as the control group, and the perioperative data of the two groups were compared. All patients in MICS-TACR group underwent postoperative angiography and the graft patency was evaluated. Results: There were no statistically significant differences in baseline data between the two groups. The perioperative blood transfusion of MICS-TACR group was less than control group [0(0,0) U vs 0(0,4) U, P=0.003]. There were no statistically significant differences in operative mortality, intraoperative and postoperative intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) use, re-operation rate, perioperative major adverse cardiac and cerebrovascular events (MACCE), new-onset renal failure, atrial fibrillation, and multiple organ failure between the two groups. Postoperative angiography showed that there was no significant difference in the patency rate between the MICS-TACR group and control group(all P>0.05). Conclusion: Total arterial coronary revascularization can be successfully accomplished under the left anterior small incision, and the early clinical outcome is satisfied.