Chih-Yang Chan

Spiral Saphenous Vein Graft for Portal Vein Reconstruction in Pancreatic Cancer Surgery

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.

Crossover Chimney Technique to Preserve the Internal Iliac Artery in Abdominal Aortic Aneurysm With Common Iliac Artery Aneurysms

Purpose To report a new technique to preserve the internal iliac artery (IIA) in cases of aortoiliac aneurysms. Technique Under bilateral common femoral artery (CFA) exposure, a crossover sheath was inserted from the contralateral CFA to the ipsilateral IIA involved in the common iliac artery (CIA) aneurysm. A Viabahn stent-graft was positioned 2 cm inside the IIA. The main body abdominal stent-graft was inserted through the ipsilateral CFA with distal sealing in the external iliac artery (EIA). The gate was cannulated, and the limb extension was positioned in the contralateral CIA near the IIA orifice. After the first Viabahn deployment, a second device was deployed with a minimum 1-cm overlap inside the first Viabahn and 2 mm distal to the limb extension. For bilateral CIA aneurysms, the Viabahn and extension limb were landed in the EIA with IIA embolization. In the past year, this technique has been used in 5 patients with success. There was no acute branch occlusion or type I endoleak from the IIA or chimney graft gutters on imaging studies up to 6 months. Conclusion This technique is easy to use and avoids the brachial access of the sandwich technique and the additional cost of an iliac branch device.

Image-guided thoracoscopic surgery with dye localization in a hybrid operating room

BACKGROUND The rate of detection of small pulmonary nodules (SPNs) has increased. Thoracoscopic resection following image-guided localization had been a reliable alternative in their treatment. We present our experience with image-guided dye localization using robotic C-arm computed tomography (CT) followed by immediate video-assisted thoracoscopic surgery (VATS) for SPNs in a hybrid operating room (OR). METHODS From July 2015 to July 2016, 25 consecutive patients with SPNs smaller than 2 cm underwent robotic C-arm CT-guided blue dye tattooing followed by immediate VATS in a hybrid OR. Their medical records were retrospectively reviewed to evaluate the feasibility and safety of this novel procedure. RESULTS Robotic C-arm CT-guided dye localization was successfully performed in 23 patients (92%). Wound extension was required for nodule identification in the remaining two patients. The median size of the nodules was 1.0 cm (range, 0.6-2.0 cm). The median needle localization time and surgery time were 46 and 109 min, respectively. All 25 patients had successful resection of their lesions. The pathological diagnoses were primary lung adenocarcinoma in 18 (72%), benign tumors in 5 (20%), and metastatic lesions in 2 (8%). There was no operative mortality. The median length of the postoperative stay was 3 days (range, 2-8 days). Complications were noted in two patients (8%). One patient had a penetrating injury of the diaphragm during needle localization. The other had pneumonia postoperatively. Both patients were managed conservatively. CONCLUSIONS Our experience showed that robotic C-arm CT-guided dye localization followed by immediate thoracoscopic surgery in a hybrid OR is safe and feasible. It may become an effective and attractive alternative in managing SPNs.

A minimal transverse incision with low median sternotomy for pediatric congenital heart surgery

OBJECTIVES Median sternotomy is the incision of choice for most cardiac surgical procedures, but the full-length vertical skin incision generally leaves an unsightly scar. In certain patients undergoing short, low-risk procedures, cosmetic considerations are of relatively greater importance. METHODS A minimal transverse curvilinear skin incision with low median sternotomy is described which gives adequate exposure for selected open-heart procedures. Since September 1997, this approach has been used in 22 pediatric patients undergoing open-heart surgery including five cases of Fallots tetralogy. We also compared the operation time and result with other approaches. RESULTS Using this modified method, the exposure of the heart was good enough, and there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. Although it took a longer time to close the wound, the operation time was similar to the standard approach. The small transverse wound was not visible under conventional clothes. CONCLUSIONS A minimal transverse incision with low median sternotomy provides an alternative approach for small wound open-heart surgery in patients with a simple congenital cardiac defect. It is technically feasible and has a good cosmetic result.

Left Ventricle Apical Conduit to Bilateral Subclavian Artery in a Patient With Porcelain Aorta and Aortic Stenosis

Severe atherosclerosis or calcification of the ascending aorta is associated with increased morbidity and mortality rates in patients who underwent cardiac operations. Several techniques had been used to avoid the manipulation of the ascending aorta during cardiac surgery. We reported our extra-anatomic approach in a patient with coronary artery disease and severe aortic stenosis with porcelain aorta. A 76-year-old man with chronic obstructive pulmonary disease, aortic stenosis, and coronary artery disease was scheduled to have cardiac surgery. After a standard median sternotomy, we found that the ascending aorta was severely calcified. The surgical strategy was changed to the construction of the composite conduit from the left ventricle (LV) apex to bilateral subclavian artery and coronary artery bypass grafting with saphenous vein. The right axillary artery and right atrium were cannulated to set up the cardiopulmonary bypass. A composite graft with a 21-mm bioprosthetic valve (Hancock II, Medtronic Inc, Minneapolis, Minn) interposed into a 22–11–11 mm Y-shaped Hemashield graft (Meadox, Hemashield, Boston Scientific, Boston, Mass) was constructed. The proximal part of the composite graft was anastomosed directly to the LV apex. The distal portions of this composite graft were anastomosed end-to-side to the bilateral subclavian artery. Intraoperative transesophageal echocardiography demonstrated a wide opened connection and unlimited blood flow from the LV apex to the conduit (Figure 1). Flow in the bilateral proximal subclavian artery showed reversed flow, which highlighted the adequacy of new LV outflow tract. The postoperative plain chest film showed the unusual location of prosthetic valve (Figure 2). Magnetic resonance angiography showed the patency of this apical composite conduit (Figure 3). The patient had an uneventful recovery. In current practice, ascending aortic calcification or atherosclerosis could be identified by epiaortic ultrasound; however, preoperative noninvasive study such as high-resolution, noncontrast computed tomography could be used for this purpose.

Infected aneurysms of the suprarenal abdominal aorta

BACKGROUND Infected aneurysm of the suprarenal abdominal aorta is rare and can be fatal without surgery. There have been only sporadic case reports or small case series. We review our experience with 14 patients over 13 years. METHODS Retrospective chart review. RESULTS Between 1997 and 2010, 14 cases of infected aneurysms of the suprarenal abdominal aorta were treated at our hospital. There were 11 men with median age of 75.5 years (range, 35-88). Of the 13 pathogens isolated, the most common responsible microorganism was nontyphoid Salmonella in eight (62%) followed by Staphylococcus aureus in three (23%) and Streptococcus in two patients (15%). At the first admission, six patients had medical treatment alone, five patients underwent early open in situ graft repair, and three patients underwent hybrid endovascular stenting and visceral debranching. Of the six medically treated patients, two patients died in the hospital because of aneurysm rupture, and two patients underwent late open in situ graft repair because of aneurysm progression or rupture. Of the five open surgically treated patients, one patient died in the hospital because of nosocomial sepsis, and four patients were alive without major postoperative complication. Of the three endovascularly treated patients, one patient died in the hospital because of intestinal ischemia, one patient died 6 months later because of postoperative complication, and one patient was alive with complications of paraplegia, renal failure, and permanent dialysis. The aneurysm-related mortality rate was 33% (2/6) in medical treatment alone, 20% (1/5) in open in situ grafting, and 67% (2/3) in hybrid endovascular stenting. CONCLUSIONS Infected aneurysm of the suprarenal abdominal aorta was rare. Nontyphoid Salmonella was the most common responsible microorganism. Open in situ graft repair remained a preferred and durable treatment strategy.

Innominate Artery Cannulation for Aortic Surgery

When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.

A Novel Bubble-Mixture Method to Improve Dynamic Images in Carbon Dioxide Angiography.

Purpose: To present a novel method of preparing carbon dioxide (CO2) for contrast enhancement.Technique: CO2 angiography can often produce poor image enhancement, especially in dependent vessels due to buoyancy of the gas. A new technique for premixing the CO2 gas with the patient’s blood and dispersing it into the bubble mixture before injection was developed. Comparative dynamic images showed bubble-mixed CO2 angiography had less fragmentation, more even distribution, and more sustainability than the same volume of pure CO2. Conclusion: The alteration of CO2 gas toward a semiliquid form demonstrates an easy and reproducible concept to improve the dynamic image quality of traditional CO2 angiography.

Recanalization of an Occluded Intrahepatic Portosystemic Covered Stent via the Percutaneous Transhepatic Approach

A 41-year-old woman with liver cirrhosis had recurrent portal hypertension and bleeding from esophageal varices due to complete occlusion of a previously inserted transjugular intrahepatic portosystemic shunt stent. Because recanalization of the stent by the transjugular approach was unsuccessful, ultrasound-guided entry to the splenic vein and portal vein was used. After catheter-directed intrathrombus thrombolysis, successful opening of the stent was achieved and a stent was placed. We herein report a rare case in which thrombolysis and recanalization of a TIPS stent were performed via a percutaneous transhepatic approach.

How to size the main aortic endograft in a chimney procedure.

The application of endovascular aortic repair in difficult circumstances, such as juxtarenal, pararenal, or thoracoabdominal aortic aneurysms, is limited. To address this difficulty, the chimney technique has been expanded and applied widely. Other than the surgeon’s individual experience and preference, however, there is currently no consensus regarding how to choose the appropriate size for the main aortic graft (MAG) parallel to the visceral chimney graft (CG) so that they accommodate each other properly inside the native aorta. Isoperimetric inequality states that among all closed curves in the plane of a fixed perimeter, a circle maximizes the area of its enclosed region. In this study, we propose a mathematical formula that was based on isoperimetric inequality to select the size of the MAG inside a known diameter of the native aorta and visceral CG: