Ara Ketchedjian

Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections

OBJECTIVEnThis study was undertaken to determine whether topical vancomycin would further reduce the incidence of sternal infections in the presence of perioperative antibiotics and tight glycemic control.nnnMETHODSnA total of 1075 consecutive patients undergoing cardiac surgery from December 2007 to August 2013 receiving topical vancomycin (2.5 g in 2 mL of normal saline) applied as a slurry to the cut edges of the sternum were compared with 2190 patients from December 2003 to November 2007 who did not receive topical vancomycin. All patients received perioperative antibiotics (cefazolin 2 g intravenously every 8 hours and vancomycin 1 g intravenously every 12 hours) on induction of anesthetic and continuing for 48 hours; and intravenous insulin infusions to maintain serum blood glucose level between 120 and 180 mg/dL.nnnRESULTSnPatients receiving topical vancomycin had less superficial sternal infections (0% vs 1.6%; P < .0001), deep sternal infections (0% vs 0.7%; P = .005), any type of sternal infection (0% vs 2.2%; P < .0001) and significantly less sternal infections of any type in patients with diabetes mellitus (0% vs 3.3%; P = .0004).nnnCONCLUSIONSnTopical vancomycin applied to the sternal edges, in conjunction with perioperative antibiotics and tight glycemic control, helps to eliminate wound infections in cardiac surgical patients.

Deep Hypothermic Circulatory Arrest and Bivalirudin Use in a Patient With Heparin-Induced Thrombocytopenia and Antiphospholipid Syndrome

Abstractu2003 Background: Patients with heparin‐induced thrombocytopenia II (HIT II) need an alternative nonheparin‐based method of anticoagulation for cardiopulmonary bypass (CPB) to prevent thrombosis and thrombosis related complications. Methods: Bivalirudin was used during CPB and deep hypothermic circulatory arrest (DHCA) for resection of multiple right atrial masses in a patient with HIT II and antiphospholipid antibodies syndrome (APS). Anticoagulation was monitored with the activated clotting time (ACT) and a target ACT of 450 seconds or greater was maintained. Results: Surgical removal of multiple right atrial masses was successful and there was no evidence of thromboembolic events. Clot was noticed in the cardiotomy and venous reservoir after CPB was discontinued and the system flushed. The postoperative course was uneventful. Conclusions: Anticoagulation was successfully managed with bivalirudin, a new short‐acting, and direct thrombin inhibitor. Further studies are necessary to evaluate the safety of bivalirudin during DHCA.

Minimally Invasive Versus Open Esophagectomy for Cancer

Despite advances in medical and radiation oncology, esophagectomy continues to remain the cornerstone of therapy for esophageal cancer when cure is the goal. The surgical approaches to esophagectomy, however, vary by institution. In many cases patients with esophageal cancer are older with significant comorbid diseases. Open approaches to esophagectomy can often carry significant morbidity and mortality for these compromised patients. Minimally invasive strategies, bolstered by improving techniques and technology, have made minimally invasive esophagectomy (MIE) a feasible operative strategy for esophageal cancer surgery. Minimally invasive surgery offers the potential for faster postoperative recovery and fewer pulmonary complications. Much like open surgery, MIE approaches and techniques differ based on institution and surgeon. The goal, however, regardless of the approach, is complete resection of all cancer.