The Egyptian Cardiothoracic Surgeon (ECTS - E-Journal)
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Endoscopic Versus Open Saphenous Vein Harvesting in Coronary Artery Bypass Grafting
Full text linkBackground: Endoscopic saphenous vein grafting has been acknowledged as a valuable method for mitigating postoperative wound scarring and associated problems.
Methods: We reviewed 60 patients who underwent coronary artery bypass surgery and had their vein graft harvested by open (OVH A, n = 30) versus endoscopic (EVH, n = 30) technique. Both groups were matched for age and sex. Wound complications were determined by the presence of ecchymosis, hematoma, keloids, dehiscence, infection, and the need for intervention. The time of harvesting was recorded routinely for each patient.
Results: When comparing open and endoscopic techniques for harvesting saphenous veins, ecchymosis was more in EVH, while wound dehiscence was more in the OVH group. Surprisingly, no significant difference between both groups regarding other wound problems, including purulent discharge. On follow-up, both groups did not show any significant difference in terms of readmissions for leg wound complications, need for plastic surgery, cosmetic satisfaction, bleeding, or recurrence of angina.
Conclusion: Endoscopic technique was associated with increased ecchymosis and reduced wound dehiscence incidence
Ascending Aortic Aneurysm Caused by Takayasu`s Arteritis: A Case Report
Full text linkTakayasu arteritis (TA) is a rare systemic vasculitis primarily affecting large and medium-sized arteries. It predominantly presents in young femalesa and can lead to significant complications, including aortic aneurysms. We present a case of a 42-year-old male with a history of TA and multiple arterial aneurysms, including an ascending aortic aneurysm measuring 5.7 cm. After routine follow-up and imaging revealed the increasing size of the aneurysm, surgical intervention was deemed necessary. The patient underwent successful surgical repair through median sternotomy and aneurysm plication on cardiopulmonary bypas
Role of Dobutamine Stress Echocardiography in Prediction of Reversibility of Moderate Ischemic Mitral Regurgitation In Patients Undergoing CABG
Full text linkBackground: Ischemic mitral regurgitation (IMR) is a frequent consequence of ischemic heart disease (IHD) and commonly occurs in patients undergoing coronary artery bypass grafting (CABG). The best approach for managing moderate IMR remains debated, especially concerning the necessity of mitral valve surgery (MVS) alongside CABG. This study evaluates the role of dobutamine stress echocardiography (DSE) in predicting the reversibility of moderate IMR and its effect on surgical outcomes.
Methods: This cross-sectional study included 60 patients with moderate IMR undergoing CABG, with or without MVS, based on DSE findings. Patients were divided into two equal groups: Group A (CABG alone) and Group B (CABG with MVS). Clinical, echocardiographic, and postoperative data were collected, and patients were followed for six months.
Results: No significant difference in short-term survival was observed between the groups. However, the CABG+MVS group showed greater improvement in IMR severity, with 96.6% achieving none-to-mild IMR at follow-up compared to 80% in the CABG-only group (p = 0.04). Additionally, the effective regurgitant orifice area (EROA) was significantly smaller in the CABG+MVS group (5.90 ± 3.63 mm² vs. 20.03 ± 8.41 mm², p < 0.001). Despite these benefits, the incidence of low cardiac output syndrome (LCOS) was higher in the CABG+MVS group (60% vs. 33.3%, p = 0.03).
Conclusion: Combined CABG and MVS significantly improves IMR severity and clinical outcomes in patients with moderate IMR but increase the risk of LCOS. Preoperative DSE is a valuable tool in selecting appropriate candidates for MVS
Early versus late surgical revascularization after acute myocardial infarction
Full text linkBackground: Optimal timing for coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) remains contentious. Early surgical intervention may minimize myocardial damage but carries increased risks, while delayed surgery allows myocardial stabilization but may lead to recurrent ischemic events.Our objectives is to compare early (0-3 days post-AMI) versus late (4-30 days post-AMI) surgical revascularization outcomes, focusing on mortality and postoperative complications.
Methods: This prospective cohort comparative study was conducted from June 2023 to May 2024 at three centers in Egypt. Sixty patients (mean age 55.67 ± 9.05 years; 85% male) undergoing CABG within 30 days of AMI were enrolled. Patients were divided into two groups based on timing: Early CABG (0–3 days post-AMI, n=30) and Late CABG (4–30 days post-AMI, n=30). Preoperative, intraoperative, and postoperative data were collected. Outcomes were assessed during hospitalization and at follow-up (mean duration 8.1 ± 1.73 months).
Results: Baseline demographic, angiographic, and echocardiographic characteristics were comparable between groups. The early CABG group showed significantly more akinetic/dyskinetic apical wall motion abnormalities (p = 0.001). In-hospital mortality was higher in the early group though without a significant difference (13.3% vs. 3.3%, p = 0.16). Postoperative complications were significantly more frequent in the early CABG group (33.3% vs. 10%, p = 0.02). The durations of ICU stay (3.83±1.36 vs. 2.37±1.71 days, p = 0.001) and total hospital stay (9.33±3.29 vs. 6.83±3.05 days, p = 0.003) were significantly longer in early CABG. Odds of complications were 4.5 times higher in early CABG while mortality odds showed a non-significant trend toward increase.
Conclusion: Early CABG may be associated with increased postoperative complications, necessitating careful patient selection and perioperative management. Delayed CABG allows for myocardial stabilization, potentially reducing perioperative risks
The challenging spectrum of mediastinal lesions and their surgical approach: Insights from a single-center experience
Full text linkBackground: Mediastinal masses represent a wide variety of pathologies. It occurs in both adults and pediatrics, and many of them are discovered incidentally. The difficult anatomical access for these lesions and their relation to important anatomical structures make diagnosis and treatment a challenge. In this study, we aimed to highlight and describe different pathologies and surgical approaches to these lesions, and to shed light on these important, challenging surgeries and the related morbidity and mortality.
Methods: We retrospectively reviewed the medical records for patients with mediastinal masses under our service between August 2020 and August 2023. Data collected included: age, sex, indication of surgery, approach, role of surgery, definitive pathology, operative time, length of hospital stay, and complications.
Results: A Total of 61 cases were included, 39 females and 22 males, with mean age 31.4 years. The mean operative time was 127.4 minutes (127.4 ± 48.0); mean hospital stay was 3.64 days (3.64 ± 4.89). The complication rate was 21.3% and perioperative mortality was 4.9%.
Conclusion: The wide spectrum of mediastinal pathologies is a challenge every time in decision-making for thoracic surgeons. The choice of surgical approach should be tailored for each case. Open surgery is still the gold standard for large or invasive lesions. Yet minimally invasive video-assisted thoracoscopic and robotic surgery has recently proven safety and efficacy for biopsies and complete resection of mediastinal masses, in selected cases treated by an experienced team
Timing of Intrapleural Streptokinase administration for Managing Post traumatic Clotted Hemothorax
Full text linkBackground: The optimal timing of intrapleural fibrinolytic therapy with streptokinase for managing posttraumatic clotted hemothorax is controversial. This study investigated the appropriate timing for fibrinolytic therapy initiation using streptokinase in post traumatic clotted hemothorax.
Methods: We conducted a randomized clinical study that included 60 patients with a clotted hemothorax recruited between December 2023 to July 2024. Patients were grouped according to the timing of intrapleural streptokinase injection into two groups. Group I (n= 30) included patients who received intrapleural streptokinase between day 3 and day 7, and Group II (n= 30) included patients who received streptokinase 7 days after the diagnosis of clotted hemothorax.
Results: There were no significant differences in age, sex, the prevalence of diabetes mellitus, hypertension, addiction, or smoking between the groups. The most common mode of trauma was stabbing wounds, with no difference in trauma mode or laterality between the groups. The number of streptokinase doses was significantly lower in patients who had streptokinase early (p<0.001), and their total drainage after administration was significantly greater than that in those who had streptokinase late (275 (200–400) vs. 100 (100–150) ml, p<0.001). The infection rate was higher in patients with late streptokinase administration (1 (3.33%) vs. 8 (26.67%), p= 0.026). No bleeding was reported in either group. The length of hospital stay was significantly longer in patients with late streptokinase administration (8 (7--9) vs. 19 (17--20), p<0.001). The success rate was 90% in the early group and 53% in the late group (p= 0.004). One patient in the early group and 23 (77%) in the late group required further surgical evacuation (p<0.001).
Conclusion: Early intrapleural administration of streptokinase (within 3–7 days of clotted hemothorax) appears to be more effective than late administration (after 7 days) for managing posttraumatic clotted hemothorax
Esophageal Complications after Anterior Cervical Spine Fixation
Full text linkBackground; Esophageal perforation may occur spontaneously, induced by a foreign body, or caused by direct trauma or iatrogenically. Anterior approach to the cervical spine surgery which was introduced in the late 1950s and extensively used since its description, is considered a known etiology for esophageal injury.
Patients and methods: We retrospectively reviewed cases of esophageal perforation that was encountered in our hospital as primary cases or referred from other hospital in between the years 2008 to 2019. All cases with esophageal injury were included. Any patient whose injury caused by other than spinal fixation was excluded.
Result: Eleven cases were encountered with a different time of presentation after surgery ranging from intraoperative discovery to 7 years post spinal fixation. Presenting symptoms were dysphagia, neck pain, persistent discharge from the cervical wound with or without food particles and odynophagia. Management plans varied from surgical intervention with primary repair, debridement, drainage, to conservative management. PEP repair was attempted in all and done in nine patients. Two patients only were treated conservatively without esophageal repair as the tear was small and in the early postoperative period. Supportive treatment in the form of frequent wound care, broad spectrum IV antibiotics, NPO and adequate feeding via alternative routes were secured as well.
Conclusion: Esophageal injury, although uncommon in anterior spinal approach, still considered a life-threatening complication and need a low threshold of suspicion from the surgeon with prompt and targeted intervention as there is no definite guide-line for the management
Early Outcomes of Thoracoscopic versus Open Extended Thymectomy in Myasthenia Gravis Patients
Full text linkBackground: The debate concerning the impact of surgical approaches for thymectomy on the outcomes of myasthenia gravis continues. This study aimed to present the preliminary outcomes of thoracoscopic versus transsternal thymectomy for patients with myasthenia gravis.
Methods: A total of 60 patients participated in this cohort study. Twenty-seven of these patients underwent thymectomy via video-assisted thoracoscopic surgery (VATS) with one (n= 7) or two ports (n= 20) (Group I). Thirty-three patients underwent thymectomy via the transsternal approach (Group II). The study was conducted over one year, and the patients were followed for three months postoperatively.
Results: The duration of the operation (88±9 vs. 131±6 min, P<0.001) and volume of blood loss (109±12 vs. 434± 54 ml; P<0.001) were significantly lower in the VATS patients. Additionally, early extubation was significantly more common in Group I than in Group II (100% vs. 48%; P <0.001). Compared with Group II patients, Group I patients had a significantly lower need for blood transfusions (0 vs. 6 (18%); P<0.001) and postoperative intensive care units (0 vs. 28 (85%); P <0.001). Compared with Group II, Group I had a lower VAS pain score after 24 h (4 (3-5) vs. 6 (6-7); P<0.001). Patient mobilization occurred significantly earlier in Group I than in Group II (5.89 ± 1.45 vs. 19.09 ± 6.38; P <0.001). No cases of video-assisted thoracoscopic surgery were converted to open surgery, and no cases of operative mortality were reported in either group.
Conclusions: Compared with open thymectomy, thoracoscopic thymectomy might yield superior results. Thoracoscopic thymectomy is associated with a shorter duration of operation, less blood loss, less need for blood transfusion, less need for the ICU, a lower pain score, and an earlier timing of patient mobilization. Therefore, thoracoscopic thymectomy could be preferable to open thymectomy for the surgical treatment of myasthenia gravis
The influence of side-to-side stapled esophagogastric anastomosis on the postoperative anastomotic complications among patients undergoing esophagectomy
Full text linkBackground: Esophageal cancer is among the most challenging tumors facing thoracic surgeons that entails a highly complex surgical procedure carrying a very high rate of morbidity and mortality. Esophagectomy procedure could be completed using several techniques depending on many factors like tumor location and surgeon preference. There are different techniques for anastomosis construction either stapled or hand sewn and there is a big debate about the ideal method for anastomosis regarding the technique and the location of construction. Our study aimed to clarify the feasibility of performing a side to side stapled cervical esophagogastric anastomosis and to study its effect on the short term outcomes after surgery.
Methods: We have conducted a prospective study for 29 consecutive patients diagnosed with esophageal carcinoma and who received esophagectomy as a curative treatment starting from January 2020 to January 2024. The study was held in Alexandria Main University Hospital.
Results: The mean age for our study group was 63.34 years ±5.31 years and females represented about 34.5%. Regarding tumor location, 13 patients (44.8%) had lower third esophageal tumor, 9 patients (31%) had middle third neoplasm, and 7 patients (24.1%) had gastroesophageal junction tumor. Regarding the anastomotic technique used, circular stapled anastomosis was done in 21 patients (72.41%). Hand sewn cervical anastomosis was used in 5 patients (17.24%) and side to side stapled cervical anastomosis was used in 3 patients (10.34%). Correlation between type of anastomosis and occurrence of leakage and dysphagia showed that anastomotic leakage has occurred in one patient with circular stapled anastomosis and in 2 patients with hand sewn anastomosis, while the side to side stapled anastomosis was not associated with any cases of leakage. Regarding the dysphagia resulting from anastomotic stricture, the side to side stapled anastomosis was not associated with dysphagia on the follow up period, while dysphagia has occurred in one patient with circular stapled anastomosis and another patient with handsewn anastomosis.
Conclusion: Side to side stapled esophagogastric anastomosis is a feasible technique and it could be associated with reduced incidence of early postoperative anastomotic leakage as well as reduced rates of late postoperative anastomotic stricture and dysphagia
Surgical management of atrial myxoma and study of its inflammatory status: A single center study
Full text linkBackground: Cardiac myxomas are rare tumors mostly located in the left atrium, less often in right atrium and occasionally in all heart chambers. The aim of the present study is to report on the early outcomes and expression of inflammatory markers associated with the surgical treatment of myxoma patients between years 2018 up to 2023.
Methods: The study included thirteen patients diagnosed with atrial myxoma. Five patients were retrospective cases under follow up and eight patients underwent prospective surgery. All patients were diagnosed by transthoracic echocardiography, then underwent median sternotomy for complete tumor resection. Left atrial myxoma was found in eleven cases while right atrial myxoma were found in two cases. Blood samples were obtained pre- and post-operatively from the eight prospective cases to determine the protein levels inflammatory markers IL-6 and TNF-α in addition to mRNA levels of IL-6.
Results: Female patients represented 69.23% of total patients. Shortness of breath was involved in 61.53%, palpitation in 15.38% and atrial fibrillation in 15.38%. of patients. Mean tumor size was 3.75±1.6 cm. No recurrence or mortality were recorded and only one case of wound infection was found (7.69%). Biochemical results revealed significant increase (p<0.05) in IL-6 levels pre-operatively (99.25 ± 8.78 pg/mL) compared to post-operatively (41.13 ± 10.40 pg/mL). Moreover, IL-6 gene expression showed down-regulation in post-operative blood samples (p<0.05). In addition, TNF-α levels were significantly increased (p<0.05) pre-operatively (97.5 ± 16.34 pg/mL) compared to post-operatively (42.38 ± 8.03 pg/mL).
Conclusion: Transthoracic echocardiography is the best diagnostic tool for myxoma diagnosis, median sternotomy with complete tumor resection decrease the rate of recurrence and mortality. Moreover, cardiac myxomas are associated with a distinct inflammatory state, evident by increased circulating inflammatory mediators as IL-6 and TNF-α which may act as markers in follow up to avoid recurrence