Background Cardiopulmonary bypass (CPB) produces a well documented diffuse inflammatory response that affects multiple organ systems. To avoid the deleterious effects of cardiopulmonary bypass, off pump coronary art...Background Cardiopulmonary bypass (CPB) produces a well documented diffuse inflammatory response that affects multiple organ systems. To avoid the deleterious effects of cardiopulmonary bypass, off pump coronary artery bypass grafting is becoming increasingly popular world wide. We reviewed our experience of complete coronary artery revascularization on the beating heart without CPB. Methods From Aug 1998 to Aug 2000, 860 off pump revascularizations (99%since January 1999) were performed at Manipal Hospital Heart Foundation. The patients consist of males 757(88%), females 103(12%). Averaged age 64.2±15 years. All surgeries were performed through a median sternotomy. Exposure techniques are tailored to individual vessels and cardiac regions. Local immobilization is performed with octopus. Vascular control is achieved with occluders and shunts. Results Among 860 off pump CABG patients. Single graft 72 (8.3%), two grafts 208 (24.2%), three grafts 469 (54.5%), four grafts 101 (11.8%), five graft 10 (1.2%). The average number of grafts per patient was 2.72±0.32. Operative mortality was 0.69%(6 patients). Anesthetic time 3.9±1.2hours, extubation time 6±2.5 hours, Blood requirement 360±90 ml, Preoperative LVEF 60.2±8.5%, Post LVEF 64.1±14%Low cardiac output 48 patients (5.6%), IABP requirement: 25 patients(2.9%), 25 patients converted to CPB during OP CAB(2.9%)and 20 of them were done with on pump beating heart. 25 patients showed myocardial ischemic and 16 patients showed perioperative myocardial infarction. ICU stay 1.1±0.8 days, hospital stay 6.2±1.1 days. Conclusion Off-pump coronary artery bypass in complete revascularization is a safe, effective technique and suitable.展开更多
Objectives To test the feasibility of the use of high thoracic epidural anesthesia as a sole anesthetic in patients undergoing off pump coronary artery bypass surgery, avoiding general anesthesia. Methods Between Octo...Objectives To test the feasibility of the use of high thoracic epidural anesthesia as a sole anesthetic in patients undergoing off pump coronary artery bypass surgery, avoiding general anesthesia. Methods Between October 2002 to April 2003, twenty five cases underwent beating heart coronary artery revascularization without endotracheal general anesthesia, using high thoracic epidural anesthesia and analgesia. All the patients underwent epidural catheterization on the evening before the surgery. Resuits The patients in all received 71 grafts (single n = 11, double n = 5, triple n = 6, quadruple n = 3). Six patients underwent repeat coronary artery bypass. Except one was converted to general anesthesia and cardiopulmonary bypass, the other patients underwent off-pump coronary artery bypass graft surgery, 2 patients underwent grafting via left thoracotomy (MIDCAB) and the rest through mid sternotomy. There was no mortality. Mean length of stay in the intensive care unit was 16 .2 ( 4.2 hours and hospital was 3.0(1.2 days. Conclusions Our experience confirms the feasibility of performing multiple coronary artery bypasses in conscious patients without endotracheal general anesthesia展开更多
Background Off-pump coronary artery bypass grafting (CABG) is becoming increasingly popular world - wide. But it is not always feasible. Current cardioplegic techniques do not consistently avoid myocardial ischemic da...Background Off-pump coronary artery bypass grafting (CABG) is becoming increasingly popular world - wide. But it is not always feasible. Current cardioplegic techniques do not consistently avoid myocardial ischemic damage. So we use on pump beating heart technique to supplement off-pump CABG. Methods Based on 860 off-pump CABG cases between Aug 1998 to Aug 2000. From Aug 1999 to Aug 2000, 46 CABG cases were performed with on pump beating heart technique at Mani-pal Hospital Heart Foundation, Bangalore, India. All surgeries were performed through a median sternotomy. Exposure techniques were tailored to individual vessels and cardiac regions and local immobilization was performed with octopus. Vascular control was achieved with occluders and shunts. Total cardiopulmonary bypass (CPB) was established before or during CABG and normolthemia was used. Results Among 46 on -pump beating heart CABG patients, 26 patients used CPB before or during OP - CABG because of unstable hemodynamics and electric instability , 7 had very deep intramyocardial left anterior descending arteries, 5 patients had poor LV function (LVEF < 30 % ), 8 patients had cardiomegaly. The average number of grafts was 3.5. No operative mortality. Three patients had postoperative myocardial infarction. Anesthetic time 4. 5±1. 2 hours, extubation time 10±2. 5 hours, blood lost 680±230 mL, blood requirement 540±150 mL, preoperative LVEF 50. 3±13 % , postoperative LVEF 64. 1±14 %, ICU stay 1. 5±0. 5 days, hospi- tal stay 9.2±1.8 days. Conclusion Complete coronary revascularization with on pump beating heart is a supplement for off - pump CABG when it is not feasible. It eliminates intraoperative globe myocardial ischemia and avoids transient myocardial injury during cardioplegic arrest and myocardial reperfusion.展开更多
Background The hemodynamics and oxygenation severely fluctuated during the offpump coronary artery bypass grafting (OPCABG) This study aimed at investigating whether or not nicardipine combined with esmolol (1∶10) ca...Background The hemodynamics and oxygenation severely fluctuated during the offpump coronary artery bypass grafting (OPCABG) This study aimed at investigating whether or not nicardipine combined with esmolol (1∶10) can maintain systemic and tissue oxygenation during OPCABGMethods Twenty patients scheduled for OPCABG were divided ramdomly into Group nicardipine (N) and Group nitroglycerine (X) respectively combined with esmolol (E) (Dosage ratio: 1 to 10) (Group N+E and Group X+E) with 10 patients in each group The mixed solution of N+E or X+E were titrated to maintain mean arterial blood pressure between 70 and 80 mmHg following anesthesia induction The variables of hemodynamics, arterial blood lactate content (Lac) and gastric intramucosal partial pressure of carbon dioxide were measured at the following time points: after induction of anesthesia (T1), prerevascularization (T2), grafting of left anterior descending (T3), right coronary descending (T4) and left coronary circumflexus branches (T5), postrevascularization (T6), the end of operation (T7) The delivery of oxygen (DO2), consumption of oxygen (VO2) and gastric intramucosal pH (pHi) were calculatedResults The cardiac index (CI) in Group N+E was significantly increased (P<005) as compared with T1 during OPCABG, while it was mildly decreased in Group X+E The stroke volumes at T4, T5 in Group N+E and at T3T6 in Group X+E were significantly decreased (P<005) The systemic vascular resistance indices in Group N+E were significantly decreased as compared with T1 (P<005) The heart rates in these two Groups were significantly elevated intraoperatively (P<005) The DO2 after the infusion of N+E was significantly increased (P<005) or leveled to T1, and the Lac were within the normal range But the DO2 in Group X+E was decreased throughout the procedure, reaching significant level at T5 (P<005), and the Lac was significantly increased beyond normal range (P<005) The pHi in Group N+E was maintained above 735 during OPCABG, while it was less than 735 from T4 to T7 in Group X+EConclusion Nicardipine combined with esmolol (1∶10) regimen may maintain systemic and tissue oxygenation during OPCABG展开更多
Cancers of the bile duct,including gallbladder cancer,extrahepatic cholangiocarcinoma,hilar and intrahepatic cholangiocarcinoma,present a significant treatment challenge.Characterized by their notorious difficulty to ...Cancers of the bile duct,including gallbladder cancer,extrahepatic cholangiocarcinoma,hilar and intrahepatic cholangiocarcinoma,present a significant treatment challenge.Characterized by their notorious difficulty to diagnose or biopsy,intricate anatomical locations and diverse clinical presentations,these malignancies collectively contribute to a significant burden on global health.The epidemiology of bile duct cancers reveals worldwide variations in incidence,prevalence,and mortality rates,emphasizing the need for a nuanced understanding of each subtype and the local environmental etiologies.Challenges in early diagnosis further compound the complexity of managing these cancers,often leading to advanced stage at the time of detection and treatment delays.Surgery remains the cornerstone of curative-intent treatment of bile duct cancers,yet the rate of recurrence and metastases underscores the importance of comprehensive multidisciplinary therapeutic strategies.Pivotal randomized clinical trials have been performed;however,they have been challenged by the lack of active agents,a limited number of accrued patients,and a grouping of all patients together regardless of where in the biliary tract the tumor originates.This has resulted in variations in treatment strategies and multiple treatment options that range from immunotherapy to radiation to hepatic artery infusion therapy(more on this later).A greater understanding of the mutational landscape of biliary tract cancers has resulted in optimism around appropriately targeted agents and combination immunotherapies.Yet,many of these regimens await robust outcomes data,and it is questionable if they significantly move the needle forward to improve overall survival.Thus now,more than ever,there is a need for updated treatment guidelines.展开更多
文摘Background Cardiopulmonary bypass (CPB) produces a well documented diffuse inflammatory response that affects multiple organ systems. To avoid the deleterious effects of cardiopulmonary bypass, off pump coronary artery bypass grafting is becoming increasingly popular world wide. We reviewed our experience of complete coronary artery revascularization on the beating heart without CPB. Methods From Aug 1998 to Aug 2000, 860 off pump revascularizations (99%since January 1999) were performed at Manipal Hospital Heart Foundation. The patients consist of males 757(88%), females 103(12%). Averaged age 64.2±15 years. All surgeries were performed through a median sternotomy. Exposure techniques are tailored to individual vessels and cardiac regions. Local immobilization is performed with octopus. Vascular control is achieved with occluders and shunts. Results Among 860 off pump CABG patients. Single graft 72 (8.3%), two grafts 208 (24.2%), three grafts 469 (54.5%), four grafts 101 (11.8%), five graft 10 (1.2%). The average number of grafts per patient was 2.72±0.32. Operative mortality was 0.69%(6 patients). Anesthetic time 3.9±1.2hours, extubation time 6±2.5 hours, Blood requirement 360±90 ml, Preoperative LVEF 60.2±8.5%, Post LVEF 64.1±14%Low cardiac output 48 patients (5.6%), IABP requirement: 25 patients(2.9%), 25 patients converted to CPB during OP CAB(2.9%)and 20 of them were done with on pump beating heart. 25 patients showed myocardial ischemic and 16 patients showed perioperative myocardial infarction. ICU stay 1.1±0.8 days, hospital stay 6.2±1.1 days. Conclusion Off-pump coronary artery bypass in complete revascularization is a safe, effective technique and suitable.
文摘Objectives To test the feasibility of the use of high thoracic epidural anesthesia as a sole anesthetic in patients undergoing off pump coronary artery bypass surgery, avoiding general anesthesia. Methods Between October 2002 to April 2003, twenty five cases underwent beating heart coronary artery revascularization without endotracheal general anesthesia, using high thoracic epidural anesthesia and analgesia. All the patients underwent epidural catheterization on the evening before the surgery. Resuits The patients in all received 71 grafts (single n = 11, double n = 5, triple n = 6, quadruple n = 3). Six patients underwent repeat coronary artery bypass. Except one was converted to general anesthesia and cardiopulmonary bypass, the other patients underwent off-pump coronary artery bypass graft surgery, 2 patients underwent grafting via left thoracotomy (MIDCAB) and the rest through mid sternotomy. There was no mortality. Mean length of stay in the intensive care unit was 16 .2 ( 4.2 hours and hospital was 3.0(1.2 days. Conclusions Our experience confirms the feasibility of performing multiple coronary artery bypasses in conscious patients without endotracheal general anesthesia
文摘Background Off-pump coronary artery bypass grafting (CABG) is becoming increasingly popular world - wide. But it is not always feasible. Current cardioplegic techniques do not consistently avoid myocardial ischemic damage. So we use on pump beating heart technique to supplement off-pump CABG. Methods Based on 860 off-pump CABG cases between Aug 1998 to Aug 2000. From Aug 1999 to Aug 2000, 46 CABG cases were performed with on pump beating heart technique at Mani-pal Hospital Heart Foundation, Bangalore, India. All surgeries were performed through a median sternotomy. Exposure techniques were tailored to individual vessels and cardiac regions and local immobilization was performed with octopus. Vascular control was achieved with occluders and shunts. Total cardiopulmonary bypass (CPB) was established before or during CABG and normolthemia was used. Results Among 46 on -pump beating heart CABG patients, 26 patients used CPB before or during OP - CABG because of unstable hemodynamics and electric instability , 7 had very deep intramyocardial left anterior descending arteries, 5 patients had poor LV function (LVEF < 30 % ), 8 patients had cardiomegaly. The average number of grafts was 3.5. No operative mortality. Three patients had postoperative myocardial infarction. Anesthetic time 4. 5±1. 2 hours, extubation time 10±2. 5 hours, blood lost 680±230 mL, blood requirement 540±150 mL, preoperative LVEF 50. 3±13 % , postoperative LVEF 64. 1±14 %, ICU stay 1. 5±0. 5 days, hospi- tal stay 9.2±1.8 days. Conclusion Complete coronary revascularization with on pump beating heart is a supplement for off - pump CABG when it is not feasible. It eliminates intraoperative globe myocardial ischemia and avoids transient myocardial injury during cardioplegic arrest and myocardial reperfusion.
文摘Background The hemodynamics and oxygenation severely fluctuated during the offpump coronary artery bypass grafting (OPCABG) This study aimed at investigating whether or not nicardipine combined with esmolol (1∶10) can maintain systemic and tissue oxygenation during OPCABGMethods Twenty patients scheduled for OPCABG were divided ramdomly into Group nicardipine (N) and Group nitroglycerine (X) respectively combined with esmolol (E) (Dosage ratio: 1 to 10) (Group N+E and Group X+E) with 10 patients in each group The mixed solution of N+E or X+E were titrated to maintain mean arterial blood pressure between 70 and 80 mmHg following anesthesia induction The variables of hemodynamics, arterial blood lactate content (Lac) and gastric intramucosal partial pressure of carbon dioxide were measured at the following time points: after induction of anesthesia (T1), prerevascularization (T2), grafting of left anterior descending (T3), right coronary descending (T4) and left coronary circumflexus branches (T5), postrevascularization (T6), the end of operation (T7) The delivery of oxygen (DO2), consumption of oxygen (VO2) and gastric intramucosal pH (pHi) were calculatedResults The cardiac index (CI) in Group N+E was significantly increased (P<005) as compared with T1 during OPCABG, while it was mildly decreased in Group X+E The stroke volumes at T4, T5 in Group N+E and at T3T6 in Group X+E were significantly decreased (P<005) The systemic vascular resistance indices in Group N+E were significantly decreased as compared with T1 (P<005) The heart rates in these two Groups were significantly elevated intraoperatively (P<005) The DO2 after the infusion of N+E was significantly increased (P<005) or leveled to T1, and the Lac were within the normal range But the DO2 in Group X+E was decreased throughout the procedure, reaching significant level at T5 (P<005), and the Lac was significantly increased beyond normal range (P<005) The pHi in Group N+E was maintained above 735 during OPCABG, while it was less than 735 from T4 to T7 in Group X+EConclusion Nicardipine combined with esmolol (1∶10) regimen may maintain systemic and tissue oxygenation during OPCABG
基金A.V.M.is supported by National Institutes of Health,National Cancer Institute(No.R37CA238435).
文摘Cancers of the bile duct,including gallbladder cancer,extrahepatic cholangiocarcinoma,hilar and intrahepatic cholangiocarcinoma,present a significant treatment challenge.Characterized by their notorious difficulty to diagnose or biopsy,intricate anatomical locations and diverse clinical presentations,these malignancies collectively contribute to a significant burden on global health.The epidemiology of bile duct cancers reveals worldwide variations in incidence,prevalence,and mortality rates,emphasizing the need for a nuanced understanding of each subtype and the local environmental etiologies.Challenges in early diagnosis further compound the complexity of managing these cancers,often leading to advanced stage at the time of detection and treatment delays.Surgery remains the cornerstone of curative-intent treatment of bile duct cancers,yet the rate of recurrence and metastases underscores the importance of comprehensive multidisciplinary therapeutic strategies.Pivotal randomized clinical trials have been performed;however,they have been challenged by the lack of active agents,a limited number of accrued patients,and a grouping of all patients together regardless of where in the biliary tract the tumor originates.This has resulted in variations in treatment strategies and multiple treatment options that range from immunotherapy to radiation to hepatic artery infusion therapy(more on this later).A greater understanding of the mutational landscape of biliary tract cancers has resulted in optimism around appropriately targeted agents and combination immunotherapies.Yet,many of these regimens await robust outcomes data,and it is questionable if they significantly move the needle forward to improve overall survival.Thus now,more than ever,there is a need for updated treatment guidelines.
