Immediate results of minimally invasive redo off-pump coronary artery bypass grafting

Coronary heart disease (CHD) ranks first among the causes of death from cardiac events. Patients who have previously undergone surgical treatment – coronary artery bypass grafting (CABG) – are not immune from the return of angina due to the progression of atherosclerosis in the native coronary arteries or degenerative changes in the shunts. Therefore, the issue of redo surgery in this group of patients is debatable.The aim of the research is to show that the use of alternative sternotomy approaches and the rejection of artificial blood circulation (ABC) are considered as possible measures to improve the results of redo CABGs.Materials and methods. In the Cardiac Surgery Unit No. 1 of the Irkutsk Regional Clinical Hospital from 2003 to 2020, 6773 off-pump CABG surgeries were performed. Of these, 6338 (93.6 %) surgeries were performed using median sternotomy and 435 (6.4 %) surgeries were performed using minitoracotomy or subxyphoid access. Of the 6338 CABG surgeries performed using sternotomy, 58 (0.9 %) were performed repeatedly. All redo surgeries during the period under review were performed by minithoracotomy or subxyphoid access. The indication for redo surgery was the return of angina of III or IV functional class, which did not respond to optimal drug therapy. When performing 54 redo surgeries, the access was leftsided mini-thoracotomy. In 3 patients, CABG was performed by subxyphoid access and in 1 patient – from right-sided mini-thoracotomy.Results. 58 redo CABG surgeries were performed. There was no damage to the access of the heart or functioning shunts. Complications were noted in 5 (8.6 %) patients. In 1 case, a second operation was required due to bleeding from the intercostal artery. In other cases, there were rhythm disturbances, or the need for inotropic support.Conclusion. Performing redo off-pump CABG surgeries using mini-accesses reduces the risk of damage to the heart and functioning shunts, eliminates manipulations on the ascending aorta, and avoids difficulties with cardioplegic protection of the myocardium with a functioning mammarocoronary graft.

Early results of different types of anorectoplasty for anorectal malformations

Objective: To document our experience with the technique of surgical repair in anorectal malformations (ARM) and the short term anatomical and functional outcomes. Methods: This study included total 31 babies. Fourteen were perineal fistula cases with age range between 1 to 4 days. Ten patients had vestibular fistula and seven had rectourinary fistula. Primary diverting colostomy was done for vestibular and rectourinary fistula patients. On the other hand low imperforate anus with anoperineal fistula without associated major anomalies had undergone fistulectomy and simple anoplasty. Results: Simple anoplasty was done for fourteen perineal fistula cases. Anterior sagittal anorectoplasty (ASARP) was done for 10 vestibular fistulae and posterior sagittal anorectoplasty (PSARP) was done in 10 recto-urinary fistula cases. Simple anoplasty and vestibular anus scored good (5-6) in 70% to 71% while PSARP scored fair in 58% of the cases. Postoperative mucosal prolapse, anal stenosis and retraction occurred in two, six and one patient respectively. Redo surgery was done in mucosal prolapse and retraction cases. Four responded to anal dilation and the other needed redo surgery by a simple cutback technique for anal stricture. Continence was assessed in 23 patients whose follow-up periods were longer than 3 years. Twenty one patients had a good score and two had a fair score. No patients had a poor score. Conclusion: Our approach has the following advantages: (i) The operative technique is simple and easy to perform. (ii) Minimal complication rate with good cosmetic results. Mediscope 2021;8(2): 75-79

Thrombolysis Versus Redo-Surgery for Treatment of Mechanical Prosthetic Mitral Valve Thrombosis in Young Adult Patients

Objectives To evaluate and compare outcome of redo-surgery and thrombolysis for treatment of mitral PVT following mechanical valve replacement for rheumatic etiology in young adult patients (<50 years old). Methods and Results This retrospective study included 42 young adult patients who had PVT after mechanical valve replacement for rheumatic mitral valve disease, between January 2014 and June 2019. Eighteen patients underwent redo-surgery and 24 patients underwent thrombolysis (Streptokinase 100,000 U/h for at least 24 hours). The approach of treatment was based on proposed criteria considering hemodynamic status, NYHA functional class, and thrombus size. Complete response to thrombolysis was defined by normal clinical and echocardiographic parameters. Primary outcome included response to thrombolysis, complications, mortality, and recurrence. The median follow-up period was 24 months. The thrombus size was significantly larger in redo-surgery group (9.88±2.44 mm2 vs 5.87±1.26 mm2, P < 0.001). The response to thrombolysis was complete recovery (70.8%), partial recovery (16.7%), or failure (12.5%). There was no significant difference in the incidence of major complications. Mortality was significantly higher in redo-surgery group (27.8% vs 4.2%, P = 0.03), with cumulative survival of 72.2% for redo-surgery versus 95.8% for thrombolysis (Log-rank P-value = 0.04). The reduced cumulative survival with redo-surgery was more evident in patients with delayed presentation (> 1 week). Recurrent thrombosis occurred only with thrombolysis (8.3% vs 0%, P = 0.20). Cumulative proportions for freedom from thrombosis were 100% for surgery versus 78.1% for thrombolysis (Log-rank P-value = 0.17). Conclusions Proper patient selection may improve outcome after treatment of mitral PVT using thrombolysis or redo-surgery in young adults. Redo-surgery has advantages over thrombolysis regarding mid-term recurrence of thrombosis; however, thrombolysis has significantly lower mortality than redo-surgery. Further evaluation of the proper treatment for delayed presentation of PVT is recommended.

Endoscopic treatment of complex multiloculated hydrocephalus in children, steps that may help to decrease revision rate

Background: Multiloculated hydrocephalus (MLH) is associated with increased intracranial pressure, with intraventricular septations, loculations, and isolation of parts of the ventricular system. Search continues for ideal surgical remedy capable of addressing the dimensions of the problem. We aimed to evaluate endoscopic septal fenestration and pellucidotomy combined with proximal shunt tube refashioning and further advancement into isolated loculations of the ventricular system containing choroid plexus. Methods: This retrospective study was conducted on 55 patients with symptomatic complex MLH who underwent endoscopic surgery. The collected data included patients’ age, gender, presenting manifestations, operative details, rate of remission of preoperative clinical and imaging signs, postoperative complications, redo surgery, or extra shunt hardware insertion. Patients were divided into Group A (underwent the standard technique of endoscopic multiseptal wide fenestration and final ventriculoperitoneal shunt insertion) and Group B (modified technique by adding extra side ports along the proximal shunt hardware). Results: Groups A and B included 25 and 30 patients, respectively. The percentage of patients showing improvement of almost all manifestations was higher in Group B compared to Group A, with no significant difference (P > 0.05). Group B had lower rate of complications (20% vs. 36%, P = 0.231), insertion of two shunts (16.7% vs. 20%, P = 1.000), and redo surgery (20% vs. 44%, P = 0.097). Conclusion: The modified technique was associated with better outcomes in terms of the use of single shunt and redo surgery. Launching randomized clinical trials to compare the two techniques are recommended to ascertain the efficacy of the modified technique.