Manoj Purohit

A simple reproducible method of preventing lobar torsion

Torsion of remaining lobes after pulmonary resection is a potentially serious complication with high reported morbidity and mortality. A range of additional procedures has been described, we have used a simple, effective, quick and easy to reproduce minor procedure to prevents torsion.

A Prospective Audit of Endoscopic Vein Harvesting for Coronary Artery Bypass Surgery

INTRODUCTION The objectives of this study were to: (i) assess the feasibility of minimally invasive endoscopic harvesting of the long saphenous vein or radial artery for use as conduit during coronary artery bypass surgery in the NHS setting; and (ii) investigate the results of endoscopic vein harvesting with regards to postoperative complications, ability to mobilise, and patient satisfaction. PATIENTS AND METHODS In this prospective audit, 25 consecutive patients, aged 52-90 years, undergoing either coronary artery bypass grafting alone or together with valve surgery or atrial fibrillation ablation were studied. All data were entered in purpose-designed proforma. Pre-operative risk factors including increasing age, diabetes, peripheral vascular disease, obesity, renal impairment, tobacco consumption and steroid use were documented. Time taken for harvest and conversion to traditional open vein harvest, quality of harvested vein in terms of number of repairs and vein damage were recorded. Postoperatively, we recorded harvest site wound complications, number of days to mobilise and total hospital stay. Pain score and patient satisfaction were also assessed. RESULTS There was one death due to myocardial infarction; another patient had postoperative cerebrovascular accident. A total of 43 lengths of grafts were harvested, 41 were long saphenous vein and two radial artery. Vein harvest time reduced significantly from a maximum of 94 min to 34 min for two lengths of long saphenous vein. Three patients required conversion from endoscopic vein harvesting to open vein harvest. The only postoperative complication directly related to endoscopic harvesting was bruising along the tunnel created by the passage of the instruments. None of the patients had any wound complication; none required antibiotics or wound debridement. Mean time to mobilise was 3.4 days. All patients who underwent successful endoscopic vein harvesting expressed satisfaction with regards to postoperative pain and cosmetic result. CONCLUSIONS Competence and ability to harvest conduit in an acceptable time frame are obtainable after a relatively low number of cases. The procedure is associated with a low number of postoperative complications and very high patient satisfaction.

Salvage therapy with topical antifungal for Aspergillus fumigatus empyema complicating extrapleural pneumonectomy

We describe an unusual case of Aspergillus fumigatus empyema and bronchopleural fistulae after extrapleural pneumonectomy (EPP) and chemoradiotherapy (CRT), which was treated successfully under salvage conditions with debridement, an innovative topical antifungal application and supplemented systemic antifungal therapy and which went on for a definitive surgical procedure. Combinations of CRT and EPP have been recommended in a select group of patients with malignant mesothelioma. Irrespective of the combination, EPP is associated with mortality in the range of 4-15% and a complication rate as high as 62%.

Single crossclamp: Safe training tool for coronary artery bypass grafting.

Objective The single-crossclamp technique for coronary artery bypass grafting is recognized to reduce manipulation of the ascending aorta, and thereby improve neurological outcomes. However, there is a perceived disadvantage of long cardiopulmonary bypass and crossclamp times. Our objective was to evaluate outcomes with this technique and determine whether it is safe for training. Methods Patients undergoing coronary artery bypass between October 2005 and February 2014 with use of the single-crossclamp method were divided into 2 groups: a consultant group (n = 1024), and a trainee group (n = 504), depending on the primary surgeon. Their outcomes were compared. Results The consultants operated on more nonelective patients who had a higher risk profile (mean additive EuroSCORE I 4.05 vs. 3.80, p = 0.085; logistic EuroSCORE I 4.36 vs. 3.64, p = 0.002). There were 9 (0.9%) deaths in the consultant group and 5 (1%) in the trainee group. The mean number of grafts in the consultant group was greater, but the crossclamp time was similar and cardiopulmonary bypass time was shorter. There were 4 (0.4%) cerebrovascular events in the consultant group and 3 (0.6%) in the trainee group. Postoperative stay was shorter in the trainee group (7.19 vs. 7.97 days, p = 0.033). Other complication rates were similar. Conclusions The technique has excellent outcomes, especially neurological, and is safe for training junior surgeons.

Can cardiothoracic surgeons provide a safe and effective thoracic surgery service

There is a trend to separate Thoracic surgery from the Cardiothoracic surgical divisions. One of the main persuasive argument is the evidence in support of increased resection rate and effective delivery of thoracic surgical services. In such context we reviewed the outcome of thoracic surgical practice in our region where a cardiothoracic surgeons service was standard.