Amit N. Patel

Saturation Technique Does Not Improve Cancer Detection as an Initial Prostate Biopsy Strategy

PURPOSE We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy. MATERIALS AND METHODS Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies. RESULTS Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group. CONCLUSIONS Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.

Pulmonary hypertension is not a risk factor for RVAD use and death after left ventricular assist system support

Unlike transplantation candidates, patients with pulmonary hypertension (PHTN) and a high transpulmonary gradient do not appear to be at increased risk for right ventricular dysfunction after left ventricular assist system implant. To verify this observation, we reviewed 63 patients supported with the HeartMate (Thermo Cardiosystems, Inc, Woburn, MA) left ventricular assist system. Patients were divided into two groups: patients with PHTN (47 patients) had mean pulmonary artery pressure > 30 mm Hg and/or pulmonary vascular resistance > 4 Wood units, and the remainder of patients did not have PHTN (16 patients). Both groups were similar in age (mean, 51 years), gender distribution (% men, 83% vs 94%, not significant), and number of patients with ischemic cardiomyopathy (72% vs 69%, not significant). More patients in the group without PHTN required extracorporeal membrane oxygenation support (38% vs 12%, p = .06). Right ventricular assist device support was instituted in five (11%) patients with PHTN and four (25%) patients without PHTN. A significantly larger number of patients without PHTN died while on support (14% vs 44%, p = .01). Survival after transplantation in both groups was > 90%. Patients with PHTN have higher transpulmonary gradient, show a significant decrease in pulmonary pressure after left ventricular assist system implantation, and have a higher transplantation rate compared to patients without PHTN. A larger patient cohort is needed to determine if the absence of PHTN is a risk factor for RVAD need and poor outcome after LVAS support.

Cardiopulmonary bypass (CPB) for lung transplantation

Surgeons have often been reluctant to use cardiopulmonary bypass (CPB) during single (SLTx) and double lung (DLTx) transplantation surgery because of the potential adverse sequelae of CPB including haemorrhage and activation of complement leading to sequestration of neutrophils and platelets in the pulmonary capillary bed, endothelial damage, increased capillary permeability and pulmonary oedema. To clarify the effect of CPB on lung transplant recipients, we reviewed our last four years’ experience in 74 patients of whom 30 required CPB support. Indications for CPB were mean pulmonary artery pressure of greater than 50 mmHg, haemodynamic instability, hypoxia or hypercarbia. Patients undergoing SLTx were placed on CPB via the femoral artery and vein, while those undergoing DLTx were cannulated in the standard fashion using the ascending aorta and right atrium. All patients were administered aprotinin prior to CPB. Intraoperatively and postoperatively, haemorrhage was not a major problem. The 30-day mortality in the CPB group and the non-CPB group were 20% and 4.6%, respectively which was not statistically significant (p = 0.06). We conclude that CPB during lung transplantation is a safe, effective method to support these severely ill patients and should not be avoided because of concerns over adverse sequelae of CPB on postoperative graft function.

Surgical management of esophageal carcinoma

Adenocarcinoma, typically in the distal third of the esopha- gus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%) (1). The incidence of adenocarcinoma is clearly increas- ing; it will soon become the most prevalent type of cancer of the esophagus. No malignant tumor in the past 25 years has increased in incidence as much as adenocarcinoma of the esophagus. The primary risk of adenocarcinoma is related to the duration and se- verity of gastric-esophageal reflux and the progression of mucosal changes from Barretts esophagus to dysplasia to adenocarcinoma. Early detection is the most important factor in determining sur- vival. Most patients present with stage IIB to stage IV disease, and most disease occurs at the gastroesophageal junction. Among patients with Barretts esophagus, the risk of devel- oping adenocarcinoma is 0.2% to 2.1% each year; 77% of patients with adenocarcinoma have had Barretts esophagus. Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma, since it could miss adenocarcinoma lo- cated somewhere else in that region. Forty percent of patients with Barretts esophagus and dysplasia have invasive carcinoma in the resected specimen. The incidence of squamous cell carcinoma, which used to be the major cause of esophageal cancer, has significantly decreased. The decrease may be related to reductions in risk factors, which include smoking, excessive alcohol use, caustic lye injury or ther- mal injury, diet, obesity, achalasia, and tylosis. Typical symptoms of esophageal cancer include difficulty swallowing, with a feeling of fullness, pressure, burning, or cough- ing; a feeling of both liquids and solids becoming stuck behind the sternum; indigestion; emesis; and weight loss. Many patients attribute their symptoms to heartburn and do not seek the medi- cal care they need.

Age related outcome after implantable left ventricular assist system support

To examine the relationship between age and outcome after implantable left ventricular assist system support, the authors investigated the results of 223 patients from 17 centers who were supported with a HeartMate (Thermo Cardiosystems, Inc., Woburn, MA) pneumatic left ventricular assist system between 1986 and 1994. In addition, the authors examined a single centers experience with 67 patients between 1992 and 1996. Ages are separated by decile and ranged from 10 to 69 years. Men dominated all age groups, averaging 82% of the total (range, 64-91%). Viral, idiopathic, and post partum cardiomyopathies were the indication for support in 88% of the patients younger than 39 years of age. Ischemic cardiomyopathy was the cause of myocardial failure in the majority of patients older than 40 years of age (40-49 years, 54%; 50-59 years, 57%; and 60-69 years, 67%). Patients aged 40-59 accounted for 64% of the patients supported, and had the best outcomes both on support and after transplantation. Survival to transplantation was not significantly different among the groups, although the patients older than 60 and younger than 69 years of age had higher mortalities on support, most commonly from cardiac failure. At the Cleveland Clinic Foundation, the survival to transplantation and survival to discharge were indistinguishable between age groups. Age does not appear to be significant risk factor for outcome after implantable left ventricular assist system support. These results predict acceptable mortality for patients supported who are older than the age of 60.

Poster presentation 2002

There are approximately 50 000 valve operations performed in the USA annually. Of these patients, 5¡/15% experience postoperative pulmonary dysfunction, with a 10% mortality. Efforts are currently underway to reduce this trend by miniaturization of the perfusion system, reduced hemodilution with rapid autologous priming of the perfusion circuit, use of bioactive coated systems, elimination of the air¡/blood interface, and pharmaceutical protocols for reduced inflammatory response. The extracorporeal perfusion circuit consists of multiple synthetic artificial surfaces whose bioincompatibility and lack of smooth surfaces predispose and subject the patient to complement mediation and activation. This results in an inflammatory process, causing the white blood cells to proliferate and sequester in the capillaries of the major organ systems. We, herein, report a retrospective matched cohort study of 500 patients who underwent valve procedures from June 1999 to May 2002. The control group consisted of patients who had a conventional arterial line filter. The study group consisted of patients who had a Pall ¡/ LGB (Pall Medical, New York) leukocyte arterial filter and a conventional arterial line filter. In the study group, the blood cardioplegia system was adapted distal to the leukocyte filter to enhance myocardial preservation with leukodepleted blood. In each group, there were 172 male and 78 female patients, whose age was 62 years (9/61). The cardiopulmonary bypass time was 112 minutes (9/ 31) and the aortic crossclamp time was 87 minutes (9/14). This patient population involved aortic valve replacement (84), mitral valve replacement (46), mitral valve repair (76), tricuspid valve repair (4), and combined valve procedures (40). Our results demonstrate that the study group achieved statistically significant data with a shorter time to extubation (p -value 0.009), fewer patients with prolonged intubation in excess of 24 hours (p -value 0.02), improved postoperative oxygenation (p -value 0.02), and decreased total length of hospital stay (p -value 0.04). There was no significant change in platelets (p -value 0.08), but there was a significant decrease in the white blood cells (p -value 0.01) comparing preand postoperative data. In summary, we believe that leukocyte filters are clinically beneficial as demonstrated by earlier extubation, improved oxygenation, and decreased length of hospital stay.

Patient selection and technical considerations for off-pump coronary surgery

The first successful operations on the coronary arteries were done without the assistance of extracorporeal circulation. Many published reports described operations performed while the heart continued beating (1–8). Advances in cardiopulmonary bypass (CPB) technology, myocardial protection, and cardiopulmonary support allowed surgeons to operate on these arteries with greater precision. It is widely accepted that the single most important development in cardiac surgery was the introduction and refinement of extracorporeal circulation via CPB. Event-free survival rates in cardiac surgery dramatically improved with advancements in myocardial protection that allowed operating in a quiet, motionless, and bloodless field. More recently, advances in 2 competing strategies, coronary artery bypass grafting (CABG) surgery and catheter-based intervention, have led to many debates regarding the optimal treatment of ischemic coronary artery disease. CABG has resulted in longer survival, better quality of life, and long-term event-free survival in patients with multivessel coronary artery disease (9–11). But what is old is new again. The option of not using the pump was the underlying assumption in the development of the concept of minimally invasive coronary surgery. Reports regarding systemic effects of CPB abound in the literature of the past 17 years. Such effects include hematologic, metabolic, pulmonary, cardiac, and cognitive dysfunctions (12–21).