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Surgical Technology International XXVIII contains peer-reviewed articles featuring the latest advances in surgical techniques and technologies.

 

April, 2016- ISSN:1090-3941

 

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Cardiovascular & Thoracic Surgery

 

Hybrid Coronary Revascularization: An Attractive Alternative Between Actual Results and Future Trends
Antonio Nenna, MD, Resident in Cardiac Surgery, Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Cristiano Spadaccio, MD, PhD, Consultant Cardiac Surgeon, Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK, Mario Lusini, MD, PhD, Consultant Cardiac Surgeon, Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Raffaele Barbato, MD, Consultant Cardiac Surgeon, Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Massimo Chello, MD, Consultant Cardiac Surgeon, Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy, Francesco Nappi, MD, Consultant Cardiac Surgeon, Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France

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Optimal revascularization strategy in patients with multi-vessel coronary artery disease remains a matter of debate, with advantages and disadvantages in both surgical and percutaneous procedures. A combined approach to achieve coronary revascularization, termed “hybrid coronary revascularization�? (HCR), has been recently introduced in clinical practice. HCR is defined as a scheduled combination of surgical left internal mammary artery to left anterior descending (LIMA-LAD) grafting and percutaneous treatment of at least one non-LAD coronary arteries, with both procedures planned and performed within a defined time limit. HCR is indicated in case of both proximal LAD disease eligible to surgical LIMA-LAD grafting and non-LAD disease amenable to percutaneous procedures. Reviews and metanalysis of the literature showed that HCR is non-inferior to conventional surgical myocardial revascularization, and in case of high-risk patients, HCR can be the ideal option. However, the various technical approaches and time-related steps need to be further evaluated. Present and future research in interventional cardiology and cardiac surgery will turn into parallel improvements in HCR procedures. Surgical revascularization with off-pump techniques and minimally-invasive approaches, scoring systems such as SYNTAX II, tools evaluating the hemodynamic significance of atherosclerotic plaques with physiology-based approaches such as fractional flow reserve and instantaneous wave-free ratio, newer generation drug eluting stents, newer antiplatelet agents, and therapies might improve indications and clinical outcomes after HCR procedures. This article reviews the current literature on HCR and aims to provide an overview about future developments.

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Lung Biopsies with the Curved Radial Reload™ Stapler
Mohamed Moneer ElSaegh, MD, FRCS-CTh, EBCTS, Registrar, The James Cook University Hospital, Middlesbrough, United Kingdom, Afroditi Petsa, MD, Registrar, Blackpool Victoria Hospital, Blackpool, United Kingdom, Joel Dunning, FRCS-CTh, Consultant, The James Cook University Hospital, Middlesbrough, United Kingdom

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Objective: We describe our experience at the James Cook University Hospital (UK) in using the curved Radial Reload™ (RR) stapler (Medtronic, Dublin, Ireland) for lung wedge resections, which is an endoscopic stapler used mainly in endoscopic general surgery.
Materials and Methods: A single center experience (James Cook University Hospital) for patients who had superficial or deep video-assisted thoracoscopic surgery (VATS) lung wedge resection, using the curved RR stapler. Results: Seven patients had superficial or deep VATS lung biopsies—their ages ranged from 38 to 75 years, with a median length of hospital stay of two days (one to six days), and a mean length of hospital stay of 2.5 days. No complications were encountered.
Conclusion: The curved RR stapler is effective in several situations and allows fewer firing of staplers. Our experience would suggest that they are as haemostatic and pneumostatic as the straight staplers and can be used effectively in both superficial and deep lung biopsies.

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Contemporary Management of Type B Aortic Dissection in the Endovascular Era
Mohsen Bannazadeh, MD, Vascular Surgery Fellow, Department of Surgery, Rami O. Tadros, MD, Associate Program Director, Associate Professor of Surgery and Radiology, James McKinsey, MD, Vice Chair, Department of Surgery, Professor of Vascular Surgery, Chief of Complex Aortic Interventions Program, Rajiv Chander, MD, Assistant Professor of Vascular Surgery, Michael L. Marin, MD, Chairman, Professor of Vascular Surgery, Peter L. Faries, MD, Chief of the Division of Vascular Surgery, Professor of Vascular Surgery, Department of Surgery, Division of Vascular Surgery, The Icahn School of Medicine at Mount Sinai, New York City, New York

 

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Aortic dissection (AD) is one of the most common catastrophic pathologies affecting the aorta. Anatomic classification is based on the origin of entry tear and its extension. Type A dissections originate in the ascending aorta, whereas the entry tear in Type B dissections starts distal to the left subclavian artery. The patients with aortic dissection who manifest complications such as rupture, malperfusion, aneurysmal degeneration, and intractable pain are classified as complicated AD. Risk factors for developing aortic dissection include age, male gender, and aortic wall structural abnormalities. The most common presenting symptom of acute aortic dissection is pain. Malperfusion occurs as a result of end-organ ischemia due to involvement of aortic branches from the dissecting process. This can happen in various locations causing mesenteric ischemia (mesenteric vessels), stroke (aortic arch vessels), renal failure (renal arteries), spinal ischemia, and limb ischemia (iliac or subclavian arteries). Aneurysmal degeneration is the most common complication of patients with chronic Type B dissection who are managed with medical therapy. Management of Type B aortic dissection (TBAD) remains controversial. Many groups recommend conservative therapy for newly diagnosed TBAD and reserve surgical management for patients who develop complications such as rupture, malperfusion, aneurysmal dilatation, and refractory pain. The mainstay of medical therapy includes antihypertensive medication to reduced ΔP/ ΔT by lowering blood pressure and heart rate. With the continued success of thoracic endovascular aortic repair (TEVAR), this procedure has been extended to treat TBAD in selected patients. The outcomes of TEVAR are promising, with early mortality rates from 10% to 20%. With promising results from these series, some groups recommend early TEVAR in uncomplicated TBAD to prevent future adverse events. The goals of endovascular treatment of TBAD are to cover the entry tear, treat or prevent impending rupture, reestablish organ perfusion, restore flow in the true lumen, and induce the false lumen thrombosis. Patients with TBAD need long-term follow-up.

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VATS Diaphragm Plication

Mohamed Moneer ElSaegh, MD, FRCS-CTh, EBCTS, Registrar, Nur Ismail, MBChB, Registrar, Joel Dunning, FRCS-CTh, Consultant, Cardiothoracic Surgery, The James Cook University Hospital, Middlesbrough, United Kingdom

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Elevated diaphragm can be due to diaphragmatic eventration or diaphragm paralysis. Diaphragm paralysis is a rare condition that can be congenital or acquired. Acquired diaphragmatic paralysis can result from injury to the phrenic nerve. Subsequently, there is loss of contractility of the diaphragm muscle leading to progressive atrophy and, hence, distension of the dome of the diaphragm leading to elevated right, left, or both copula of the diaphragm. Diaphragm plication aims to return the abdominal contents back to their normal position and allow for greater lung expansion by reducing the abundant diaphragmatic surface. Traditionally, diaphragm plication was performed through thoracotomy, until 1996 when Moroux introduced the widely used thoracoscopic technique of diaphragm plication. With the advancement of minimally-invasive surgery over the years, the approach to diaphragm plication has evolved from four ports to an uniportal approach and robotics.

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