Shao-Jung Li

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.

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.

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.

Less Invasive Mitral Valve Surgery via Right Minithoracotomy

BACKGROUND/PURPOSE Current trends in cardiac surgical intervention are moving toward less invasiveness, with smaller wound or sternum-sparing, less pump time or off-pump, and beating rather than arrested heart. Data on the efficacy and safety of these newer less invasive techniques, as well as their cosmetic results, are limited. This study analyzed the results of a sternum-sparing mitral valve operation. METHODS Thirty patients with mitral valve diseases, including 20 who underwent mitral valve repair and 10 mitral valve replacement, were enrolled. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest was induced by using a percutaneous, transthoracic cross-clamp. The main surgical wound was made over the lateral border of the right breast. Two additional small wounds were required for the transthoracic aortic clamp and the mitral retractor. RESULTS There was no operative mortality, and all patients had an uneventful recovery. Two patients underwent redo mitral surgery. Nine associated procedures were performed including tricuspid valve annuloplasty in six patients, tricuspid valve replacement in two patients and atrial septal defect repair in one patient. The length of the main wound was between 5.8 and 7.8 cm (mean, 7.1 cm). The mean cardiopulmonary bypass time and cross-clamp time were 91.1 and 43.7 minutes, respectively. Although the length of stay was not significantly reduced compared with traditional median sternotomy, all patients had satisfactory results with good cosmesis. CONCLUSION Sternum-sparing mitral valve surgery appears to be a safe and effective alternative to conventional mitral valve surgery; it is less invasive and provides superior cosmetic results for patients.

Endovenous Laser Treatment for Varicosities in Lower Extremities

Objective: To retrospectively analyze the results of treatment on Taiwanese patients with primary varicosities of the lower extremities including concomitant use of endovenous laser, phlebectomy, and sclerotherapy. Methods: We routinely used tumescent anesthesia and ultrasound-guided approaches for the application of endovenous laser. Vein access was achieved by either a percutaneous or stab wound. The laser power was usually 10-14 watts, laser treatment usually was begun from 4 cm below the saphenofemoral junction, and stopped around the knee, not over 10 cm below the knee. In the same operation, we used Mueller s phlebectomy and/or sclerotherapy if there were prominent branch varicosities. We instructed each patient to walk around immediately after the operation, to go home, and to come back 1-3 days later for follow-up. Results: One hundred and eighteen limbs in 102 patients were treated with the ambulatory method from October 2003 to December 2004. Using ultrasound-guidance and perivenous tumescent anesthesia, endovenous placement of laser fiber was achieved in each case. The laser delivery rates we used were 43.68±27.28 joules/cm, with fluency of 18.47±13.48 joules/cm square. The mid-term results 12 to 24 months after surgery indicated a 96.61% success rate. There was no failure when laser fired above 17.24 joules/cm or 5.49 joules/cm square. Thirty-two (32) limbs had concomitant Mueller s ambulatory phlebectomies and 33 limbs sclerotherapies. All patients could walk around immediately after the treatment. The 1st - 3rd postoperative day pain score was 2.94±1.91, and no serious complications occurred. Conclusions: With the use of ultrasound guidance and tumescent anesthesia, endovenous laser treatment with concomitant phlebectomy and sclerotherapy for primary varicosities of the lower extremities can be safely and effectively done on an out-patient basis for Taiwanese patients. Neither bed-rest nor hospitalization is necessary.

Endoscope-Assisted Minimally Invasive Surgery for Coronary Artery Bypass

Objective: Cardiac surgeons began in this decade to apply the endoscopes in their practices. Endoscopic graft harvest for coronary artery bypass surgery (CABG) has become the routine practice in many institutes. However, endoscopic harvest of the left internal mammary artery (LIMA) has remained a technical challenge. Methods: From April 2002 to April 2004, 40 patients underwent minimally invasive direct CABG using LIMA to left anterior descending (LAD) artery bypass. Twentyone of them had endoscopic harvest of LIMA. Results: There was neither early nor late operative mortality. Endoscopic LIMA harvest time ranged from 38 to 125 minutes (mean 56 minutes). All harvested LIMAs had a burst flow while being cut from the distal end. The length of thoracotomy was 5 to 8 cm (mean 6.2 cm).Ten patients were extubated immediately. One patient had hemothorax which required chest tube insertion. The intensive care unit (ICU) ventilation time was 0 to 40 hours (mean 7 hours). The ICU stay and hospital stay were 1.3±0.3 and 6.2±1.5 days, respectively. Conclusions: Endoscope-assisted LIMA harvest is a feasible technique. The learning curve, however, shows that this approach reduces wound length, recovery time, and helps extend the graft length to facilitate the anastomosis. It provides patients with an alternative choice to have a satisfactory conduit in a minimally invasive way.

Caval Inflow Occlusion during Surgery for Tricuspid Infective Endocarditis: Report of a Case

The technique of normothermic caval inflow occlusion was introduced more than 50 years ago, and it was well established and used extensively before the era of cardiopulmonary bypass. It had been used in various cardiac situations where a period of up to 2 minutes of intracardiac exposure was sufficient. However, this technique was rarely used recently, especially for adult cardiac procedures. Almost every open heart surgery was performed under the assistance of cardiopulmonary bypass which provided a motionless and bloodless surgical field. Here we report our experience of tricuspid valve surgery using caval inflow occlusion in adults. Three infective endocarditis patients with multiple pulmonary emboli, congestive heart failure and uncontrolled sepsis underwent tricuspid valve vegetectomy without cardiopulmonary bypass. Right atria were opened and infected leaflets were excised after occlusion of both vena cava. All these patients had good recovery. The detailed surgical managements were described.

Hybrid angioplasty for left pulmonary artery stenosis after total correction of tetralogy of fallot : Report of one case

Pulmonary artery stenosis is common in tetralogy of Fallot. Surgical correction usually achieves good results. For those patients undergoing total correction with residual pulmonary artery stenosis, percutaneous transluminal angioplasty (PTA) plays an important role. However, this might not be possible for complex anatomies. We report a 19-month-old boy who underwent total correction of tetralogy of Fallot at 1 year of age. He developed main pulmonary artery (MPA) aneurysm and left pulmonary artery (LPA) stenosis 4 months after the operation. PTA was attempted, but the guidewire failed to thread into the LPA due to the dilated MPA and tiny LPA ostium. A hybrid approach consisting of left anterior small thoracotomy and balloon angioplasty via the introducer sheath in the MPA was proposed. Rapid access to the LPA and successful balloon angioplasty followed by stenting concluded the hybrid intervention. Such intervention is a good alternative to treat this complex anatomy.