Paul Waterworth

Randomized Prospective Study Comparing Conventional Subcuticular Skin Closure With Dermabond Skin Glue After Saphenous Vein Harvesting

BACKGROUND Dermabond (Ethicon UK, Edinburgh, United Kingdom) is a topical skin adhesive used for surgical wound closure, with purported advantages over conventional sutures on cosmetic outcomes, cost benefits, and operative times. This study compared results of skin closure using Dermabond and subcuticular sutures after coronary artery bypass grafting (CABG). METHODS The study prospectively enrolled and randomized 106 patients who underwent CABG. The groups received closure with Dermabond skin glue or subcuticular sutures (n = 53 each) after saphenous vein harvesting using the bridging technique. Wound closure time for the two methods was recorded. Cosmetic appearance was assessed using the Hollander, the Vancouver, and the visual analog scale. Patient satisfaction was recorded before discharge and at week 6. RESULTS There were no significant differences in the total operative time between the two groups (p = 0.43). Closure time was significantly shorter in the Dermabond group (p = 0.017). Patients in the Dermabond group also reported superior cosmetic outcome at weeks 1 (p < 0.001) and 6 (p = 0.001) and improved patient satisfaction (p < 0.001). CONCLUSIONS Dermabond has demonstrated superiority over traditional subcuticular skin sutures in terms of closure time, cosmetic appearance, and patient satisfaction. This technique provides a novel method of wound closure after CABG.

A randomized study comparing three groups of vein harvesting methods for coronary artery bypass grafting: endoscopic harvest versus standard bridging and open techniques

OBJECTIVES The use of an open vein harvesting (OVH) technique for saphenous vein harvesting (SVH) is associated with wound complications and delayed patient mobilization. This has led to the development of minimally invasive vein harvesting (MIVH) techniques, such as standard bridging and endoscopic SVH (EVH). This randomized trial was established to assess immediate clinical outcome and patient satisfaction in our centre. METHODS A total of 150 consecutive patients were prospectively randomized into three groups. Group 1 consisted of 50 patients who underwent OVH, Group 2 consisted of 50 patients who underwent a standard bridging technique (SBT) and Group 3 consisted of 50 patients who underwent EVH. Each group was assessed for the incidence of wound infection, postoperative pain and satisfaction and the number of vein repairs using previously validated scoring systems. RESULTS The MIVH techniques reduced the pain at hospital (P < 0.001) and at 6 weeks (P < 0.001), and improved cosmesis (P < 0.001), compared with the OVH group. Patient satisfaction was greatest in the EVH group followed by the SBT and then the OVH group. The clinical markers of inflammation were reduced with an MIVHt. There were more vein repairs in the EVH compared with the OVH (P < 0.001) and the SBT (P = 0.04) groups. CONCLUSIONS This study demonstrates that MIVH reduces wound morbidity. We believe that each technique has advantages and disadvantages, which should be considered during the selection of a harvesting procedure by both the patient and the surgeon.

A comparative analysis of saphenous vein conduit harvesting techniques for coronary artery bypass grafting – standard bridging versus the open technique

Coronary artery bypass graft (CABG) surgery involves harvesting the great saphenous vein (GSV) using the traditional open technique (TOT). This can be associated with significant leg morbidity and patient dissatisfaction. Alternatively, the standard bridging technique (SBT) is a minimally invasive procedure of vein retrieval that uses smaller frequent incisions along the length of the leg and may reduce postoperative complications. This study was designed to compare the success of SBT in reducing leg morbidity and increasing patient satisfaction. One hundred patients were recruited into the study and computer randomised into two groups of 50 undergoing SBT or TOT. Leg morbidity and patient satisfaction were analysed by assessment of pain scores, wound development and scar formation. Closure and harvesting time were also compared between the two groups. SBT was associated with better wound development (P<0.001) and a significantly higher patient satisfaction (P<0.001). Leg pain was significantly reduced amongst SBT group at rest and with movement (P<0.001). There was also a reduction in saphenous neuropathy with the use of SBT (P<0.001). No difference in closure or harvesting time was demonstrated (P=0.26 and P=0.23, respectively). This study demonstrates that harvesting the GSV by the minimally invasive SBT reduces postoperative leg morbidity and increases patient satisfaction without the need of costly equipment. SBT represents a safe, effective and financially viable technique for vein harvesting.

A randomized study comparing traditional monofilament knotted sutures with barbed knotless sutures for donor leg wound closure in coronary artery bypass surgery

OBJECTIVES Surgical knots on the suture line provide an anchoring function, but also represent a potential source of infection and irritation on the donor leg after coronary artery bypass surgery. Knotless barbed sutures were designed to prevent knot-related complications. This study compared knot-related wound complication rates between patients receiving traditional monofilament sutures and those receiving barbed knotless sutures for closure of the donor leg. METHODS One hundred and forty-two patients were randomized into two groups. Group 1 (n = 70) received traditional monofilament sutures and Group 2 (n = 72) received barbed knotless sutures. All wounds were assessed on postoperative days 3 and 5 and weeks 2, 4 and 6 using a validated wound scoring system. Antibiotics usage and general practitioner and district nurse visits were recorded. RESULTS No demographic differences were observed between groups. Leg wound skin closure times were significantly shorter in Group 2 compared with Group 1 (P < 0.001). Group 1 demonstrated a greater incidence of excessive scarring (P < 0.001), itching (P < 0.001), irritation (P < 0.001) and adverse skin tissue reactions (P < 0.001) than Group 2. Fewer general practitioner visits were recorded in Group 1 compared with Group 2 (P = 0.051). CONCLUSION Knotless barbed suture usage significantly reduces the incidence of knot-related leg wound complications compared with traditional monofilament knotted sutures. This may be related to differences in the rate of absorption of the suture material or an associated decrease in the incidence of adverse skin tissue reactions that may delay postoperative wound healing.

Does the introduction of a comprehensive structured training programme for endoscopic vein harvesting improve conduit quality? A multicentre pilot study

OBJECTIVES Endoscopic vein harvesting is one of the most popular minimally invasive vein-harvesting techniques for coronary artery bypass graft surgery. It is associated with improved cosmetic outcome and fewer wound-related problems compared with the conventional open technique. However, its efficacy with regard to conduit damage and long-term patency has recently been questioned. Learning curve-associated trauma to the vein has a major impact on vein quality and the incidence of graft failure post-surgery. In an attempt to address this problem, we have devised and tested a learning tool termed Manchester Endoscopic Learning Tool (MELT). In this study, we compare vein quality following MELT training with standard recommended training. METHODS Fourteen practitioners across seven UK centres were enrolled into the study. Practitioners were categorized into two groups receiving MELT or standard training. Data were collected prospectively from the first eight vein retrievals per operator following training. A total of n = 112 vein-harvesting procedures were included in the study. RESULTS Veins harvested by MELT practitioners had fewer small avulsions (P <0.001), required fewer repairs (P <0.001) and experienced a lower incidence of bruising (P <0.001) than veins obtained by practitioners receiving standard training. The incidence of very short side branches requiring repair was also significantly reduced (P <0.001) in the MELT group compared with standard training. CONCLUSIONS Our formalized training programme consistently minimizes vein trauma resulting in better-quality conduits when compared with the current standard training. Exposure of surgical practitioners to the structured curriculum during their endoscopic vein harvesting training will enhance their learning and lead to better-quality conduits. This is likely to impart clinical benefit post-surgery.

Can the temporary use of right ventricular assist devices bridge patients with acute right ventricular failure after cardiac surgery to recovery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Can the temporary use of right ventricular assist devices (RVADs) bridge patients to recovery who suffer acute right ventricular failure after cardiac surgery? More than 183 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Indications for surgical intervention included coronary artery bypass surgery, valve replacement, post-heart transplant and left ventricular assist device insertion. Significant reductions in central venous pressure (P = 0.005) and mean pulmonary artery pressures (P < 0.01) were reported during and after RVAD support. Furthermore, increases in right ventricular cardiac output (P < 0.05), right ventricular ejection fraction (P < 0.05), right ventricular stroke work (P < 0.05) and pulmonary artery oxygen saturations (P < 0.05) were also seen. Assessment by one study showed that on Day 7 after RVAD removal, the right ventricular ejection fraction had increased by up to 40%. Dynamic echocardiography studies performed before, during and after RVAD placement demonstrated that after RVAD implantation, right ventricular end-diastolic dimensions (P < 0.05) and right atrial dimensions decreased (P < 0.05) and right ventricular ejection fraction (P < 0.05) increased. Although several studies successfully weaned patients from an RVAD, there were several complications, including bleeding requiring surgical intervention. However, this may be reduced by using percutaneous implantation (bleeding incidence: 4 of 9 patients) rather than by a surgically implanted RVAD (bleeding incidence: 5 of 5 patients). However, mortality is higher in percutaneous RVAD patients rather than in surgical RVAD (80-44%) patients. Causes of death cited for patients on an RVAD included multiorgan failure, sepsis, thromboembolic events, reoccurring right heart failure and failure to wean due to persistent right ventricular failure. We conclude that RVADs have been successfully used to bridge patients to recovery after cardiac surgery; however, RVADs carry numerous risks and a high mortality rate.

Does the use of thiopental provide added cerebral protection during deep hypothermic circulatory arrest

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Does the use of thiopental provide added cerebral protection during deep hypothermic circulatory arrest (DHCA)? Altogether, more than 62 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four of the seven papers used thiopental alongside other neuroprotective methods and agents. The methods included the use of ice packs to the head and core systemic hypothermia. Agents used alongside thiopental included nicardipine and mannitol. Thiopental was found to have the ability to lower oxygen consumption, where oxygen consumption was measured using the phosphocreatinine and adenosine triphosphate ratio. The neuroprotective effect of thiopental was evaluated by assessing the electrical activity of the brain during circulatory arrest, by which it was shown to be advantageous. However, other trials suggested that adding thiopental during circulatory arrest did not provide any extra protection to the brain. The timing of thiopental administration is of importance in order to gain positive outcomes, as its ability to lower the cerebral energy state may result in unfavourable results if added before hypothermic circulatory arrest, where this may lead to an ischaemic event. We conclude that the use of thiopental during deep hypothermic circulatory arrest is beneficial, but if administered too early, it may replete the cerebral energy state before arrest and prove to be detrimental.

Closed suction drainage improves clinical outcome in patients undergoing endoscopic vein harvesting for coronary artery bypass grafting.

BACKGROUND Endoscopic vein harvesting (EVH) is a widely accepted technique for coronary artery bypass grafting, with well-reported benefits. However, EVH is associated with severe hematoma formation at incision sites, resulting in postoperative pain. We hypothesized that the use of a leg wound drain at the incision site may reduce these comorbidities. METHODS One hundred consecutive patients were prospectively randomly allocated into two groups of 50: group 1 with leg wound drains, and group 2 without drains. Group 1 patients underwent EVH followed by closure with a size 10 high vacuum leg wound drain (20 kPa), whereas group 2 underwent EVH followed by closure without a leg wound drain. Patients were assessed for postoperative pain, wound infection, and satisfaction using validated scoring systems immediately after surgery. RESULTS Pain at rest (p < 0.001) and with movement (p < 0.001), incidence of hematoma (p < 0.001), and patient satisfaction (p < 0.001) were significantly improved in the drain group at days 1 to 7 and remained significant at week 6 after surgery. Interestingly, the use of antibiotics (6% versus 24%, p = 0.012) and the number of general practitioner visits (6% versus 26%, p = 0.012) were lower in the drain group compared with the no-drain group. However, there were no differences in the length of hospital stay between the two groups after surgery. CONCLUSIONS Our findings indicate that the use of a high vacuum leg drain after EVH for long saphenous vein is of clear therapeutic benefit in the early postoperative period. We also report that this technique may reduce antibiotic administration and general practitioner visits after patient discharge.

Scrotal Distension After Endoscopic Harvesting of the Saphenous Vein in Patients With Inguinal Hernia

The great saphenous vein remains the most commonly used conduit for coronary artery bypass grafting. The endoscopic vein harvesting technique is widely used due to reduced postoperative complications. We present the case of 5 patients with a history of inguinal hernia undergoing coronary artery bypass grafting, which resulted in CO2 infiltration through the deep inguinal ring and into the scrotum leading to acute scrotal enlargement. Due to the risk of impediment of vascular blood supply and necrosis, endoscopic vein harvesting was withdrawn, and the vein was harvested by using the bridging technique. Postoperatively, severe contusion, inflammation, and erythematous vesicular eruption resulted in a lengthened hospital stay.

Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins Using 2 Types of Endoscopic and Open Vein Harvesting

Objective The aim of the study was to assess whether the use of carbon dioxide insufflation has any impact on integrity of long saphenous vein comparing 2 types of endoscopic vein harvesting and traditional open vein harvesting. Methods A total of 301 patients were prospectively randomized into 3 groups. Group 1 control arm of open vein harvesting (n = 101), group 2 closed tunnel (carbon dioxide) endoscopic vein harvesting (n = 100) and Group 3 open tunnel (carbon dioxide) endoscopic vein harvesting (open tunnel endoscopic vein harvesting) (n = 100). Each group was assessed to determine the systemic level of partial arterial carbon dioxide, end-tidal carbon dioxide, and pH. Three blood samples were obtained at baseline, 10 minutes after start of endoscopic vein harvesting, and 10 minutes after the vein was retrieved. Vein samples were taken immediately after vein harvesting without further surgical handling to measure the histological level of endothelial damage. A modified validated endothelial scoring system was used to compare the extent of endothelial stretching and detachment. Results The level of end-tidal carbon dioxide was maintained in the open tunnel endoscopic vein harvesting and open vein harvesting groups but increased significantly in the closed tunnel endoscopic vein harvesting group (P = 0.451, P = 0.385, and P < 0.001). Interestingly, partial arterial carbon dioxide also did not differ over time in the open tunnel endoscopic vein harvesting group (P = 0.241), whereas partial arterial carbon dioxide reduced significantly over time in the open vein harvesting group (P = 0.001). A profound increase in partial arterial carbon dioxide was observed in the closed tunnel endoscopic vein harvesting group (P < 0.001). Consistent with these patterns, only the closed tunnel endoscopic vein harvesting group demonstrated a sudden drop in pH over time (P < 0.001), whereas pH remained stable for both open tunnel endoscopic vein harvesting and open vein harvesting groups (P = 0.105 and P = 0.869, respectively). Endothelial integrity was better preserved in the open vein harvesting group compared with open tunnel endoscopic vein harvesting or closed tunnel endoscopic vein harvesting groups (P = 0.012) and was not affected by changes in carbon dioxide or low pH. Significantly greater stretching of the endothelium was observed in the open tunnel endoscopic open tunnel endoscopic vein harvesting group compared with the other groups (P = 0.003). Conclusions This study demonstrated that the different vein harvesting techniques impact on endothelial integrity; however, this does not seem to be related to the increase in systemic absorption of carbon dioxide or to the pressurized endoscopic tunnel. The open tunnel endoscopic harvesting technique vein had more endothelial stretching compared with the closed tunnel endoscopic technique; this may be due to manual dissection of the vein. Further research is required to evaluate the long-term clinical outcome of these vein grafts.