Concomitant coronary bypass grafting and curative surgery for cancer

Simultaneous surgical management of malignancy and coronary heart disease

Coronary heart disease and cancer are the most common causes of mortality across the globe. It has been a dilemma for the surgical team to decide which surgical procedure should be done first when a patient needs surgery for both. This is a single-center retrospective observational study. Six patients who underwent simultaneous coronary artery bypass graft (CABG) and oncological surgeries between January 2018 and July 2021 were included in the study. One patient underwent lung bilobectomy via the same sternotomy incision; one underwent surgery for breast cancer, stomach cancer, and colon cancer; and one patient each of buccal mucosa carcinoma and tongue carcinoma. The median age was 65 years (59-70). Median blood loss was 550 ml (400-800). The median intensive care unit (ICU) stay was 60 h (46-130) and hospital stay was 7.5 days (6-14). The median follow-up of the present study was 31.5 months (6-38). One patient with lung carcinoma developed recurrence after 6 months and the patient is in remission after a follow-up of 32 months. Simultaneous CABG and oncological resection can be performed effectively and safely by an experienced team of cardiothoracic surgeons, surgical oncologists, and anesthetists after good patient selection.

Feasibility of radical gastrointestinal tumor resection with simultaneous off-pump coronary artery bypass surgery for patients with severe heart problems: A retrospective cohort study from a single institutional database

PURPOSE

Clinical treatment of gastrointestinal neoplasms in patients with severe coronary stenosis is difficult, and it remains controversial to perform staged or simultaneous surgeries. The purpose of this study was to retrospectively analyze the feasibility and indications for simultaneous gastrointestinal tumor resection and off-pump coronary artery bypass (OPCAB) graft surgery.

METHODS

Data collected from a total of five patients, including three patients with gastric cancer and two patients with colorectal cancer, who underwent simultaneous radical cancer resection and OPCAB between September 2010 and October 2019, were retrospectively analyzed. Among these patients, one had an incomplete colonic obstruction. All patients had severe coronary stenosis, and one experienced acute heart failure before surgery. OPCAB was performed first, followed by the radical cancer resection.

RESULTS

All five patients were discharged from hospital without perioperative death, major cardiovascular events or anastomotic leakage. The mean postoperative hospital stay was 9.4 days. One patient experienced slight gastrointestinal bleeding after surgery, which improved with conservative treatment. After a mean follow-up of 39 months, two patients with gastric cancer died from tumor metastasis at 28 months and 37 months, while the remaining three patients did not have tumor recurrence or metastasis. None of the patients experienced myocardial ischemia.

CONCLUSION

It is safe and feasible to perform simultaneous OPCAB and gastrointestinal surgeries on the premise of strictly controlling the indications for patients with gastrointestinal tumors complicated with severe coronary artery stenosis.

Treatment of simultaneously discovered lung cancer and cardiovascular disease: a 20-year single-institution experience

PURPOSE

To propose a treatment strategy for simultaneously discovered non-small cell lung cancer (NSCLC) and cardiovascular disease (CVD).

METHODS

Of 1302 patients who underwent surgery for NSCLC, CVD requiring invasive treatment was simultaneously discovered in 33 (3 %). The details of the treatments as well as the short- and long-term outcomes of pulmonary resection were analyzed.

RESULTS

CVD included coronary artery disease in 20 patients, valvular disease in 6, abdominal aortic aneurysm in 5, and congenital heart disease in 2. Twenty-six patients underwent two-stage treatment, while seven received simultaneous surgery. In 23 patients whose treatment for CVD preceded that for lung cancer, the median interval between those treatments was 78 days (range 18-197 days). Postoperative complications occurred in 8 (31 %) of 26 patients who underwent 2-stage treatment and in 3 (43 %) of 7 who underwent simultaneous surgery. Notably, of 3 patients who underwent lobectomy or bilobectomy, 2 (67 %) experienced respiratory dysfunction that required intubation. The 5-year overall survival rate of all 33 patients was 84.5 %.

CONCLUSION

The outcomes of two-stage treatment in the present cohort were favorable. Given our experience, simultaneous surgery for lung cancer and CVD should, therefore, be selected only for patients who may benefit from that strategy.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

BACKGROUND

Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.

METHODS

Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses.

RESULTS

The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.

CONCLUSIONS

Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Simultaneous radical gastrectomy and coronary artery bypass grafting: a case report

Coexistence of coronary artery disease and cancer with both requiring surgical treatment at the same time is rare. A 74-year-old male underwent elective coronary artery bypass grafting for unstable angina. In preoperative workup, the patient was incidentally discovered to have anaemia secondary to occult blood loss in his stool. This led to a preoperative upper GI endoscopy which showed a gastric carcinoma. Since both conditions required surgery, it was decided to perform simultaneous coronary artery bypass grafting (CABG) followed by distal radical gastrectomy. CABG was done using low-dose heparin, and after closing sternotomy, the radical gastrectomy was performed. Postoperative recovery was uneventful, and patient was discharged in stable condition on day 14. Follow-up after 6 months revealed no recurrence. Feasibility of simultaneous CABG and gastric cancer surgery, in particular, and various management strategies, in general, is discussed.

Simultaneous operation for cardiac disease and gastrointestinal malignancy

AIM: To investigate the safety of performing simultaneous cardiac surgery and a resection of a gastrointestinal malignancy.

METHODS: Among 3664 elective cardiac operations performed in adults at Kagoshima University Hospital from January 1991 to October 2009, this study reviewed the clinical records of the patients who underwent concomitant cardiac surgery and a gastrointestinal resection. Such simultaneous surgeries were performed in 15 patients between January 1991 and October 2009. The cardiac diseases included 8 cases of coronary artery disease and 7 cases with valvular heart disease. Gastrointestinal malignancies included 11 gastric and 4 colon cancers. Immediate postoperative and long-term outcomes were evaluated.

RESULTS: Postoperative complications occurred in 5 patients (33.3%), including strokes (n = 1), respiratory failure requiring re-intubation (n = 1), hemorrhage (n = 2), hyperbilirubinemia (n = 1) and aspiration pneumonia (n = 1). There was 1 hospital death caused by the development of adult respiratory distress syndrome after postoperative surgical bleeding followed aortic valve replacement plus gastrectomy. There was no cardiovascular event in the patients during the follow-up period. The cumulative survival rate for all patients was 69.2% at 5 years.

CONCLUSION: Simultaneous procedures are acceptable for the patients who require surgery for both cardiac diseases and gastrointestinal malignancy. In particular, the combination of a standard cardiac operation, such as coronary artery bypass grafting or an isolated valve replacement and simple gastrointestinal resection, such as gastrectomy or colectomy can therefore be safely performed.

Minimally invasive surgery for lung cancer with coronary artery disease

We report a 69-year-old woman with lung cancer and severe stenosis in the left anterior descending coronary artery. To perform a curative operation for the lung cancer without myocardial infarction, minimally invasive direct coronary artery bypass and left lower lobectomy with video-endoscopic assistance were performed simultaneously. There was no major complication, and she was discharged at 14 days after the operation. This procedure may be useful and safe for patients with lung cancer and coronary artery disease.

Surgical management of coronary artery disease associated with malignancy

Surgical management of patients with combined coronary artery disease and malignancy remains a challenge. In this review the time of surgical intervention, whether to treat the malignancy or the coronary artery disease first, and which bypass technique should be used during myocardial revascularization are reviewed to determine the most optimal strategy to manage patients who require coronary surgical revascularization and present with an underlying malignancy.

Simultaneous nephrectomy and coronary artery bypass grafting through extended sternotomy

Background

The advances in surgical techniques, resuscitation and anesthesiology support over the last years have allowed simultaneous thoracic and abdominal operations to be made for cancer and concomitant severe heart vessel disease relieving the patient from several diseases simultaneously and achieving long lasting remission or cure.

Clinical case

A simultaneous nephrectomy and coronary artery bypass grafting procedure through extended sternotomy is reported. A 63-year-old man with severe coronary artery disease was found to have renal carcinoma.

Diagnosis

Postoperative pathological investigation of the tumor revealed the presence of renal cell carcinoma pT3a N0 M0, G2. Coronarography revealed advanced three-vessel coronary artery disease.

Treatment

We successfully performed a simultaneous curative surgery for renal carcinoma and coronary artery bypass graft surgery under cardiopulmonary bypass using a novel technique of extended sternotomy. Simultaneous surgery thus appears to be a beneficial and safe approach for the treatment of coronary artery disease and resectable renal cancer in carefully selected patients.

Report of simultaneous off-pump CABG and modified mastectomy

The patient was a 75-year-old female who had received medical treatment for effort angina. Recently, she noticed a left breast tumor, which was diagnosed as breast cancer with axillary lymph node swelling. Coronary angiography performed prior to the surgery for the breast cancer showed 90% stenosis in segment 6 of the left anterior descending artery (LAD). Coronary intervention was not possible due to anatomical reasons, so she was admitted for simultaneous surgery for the breast cancer and angina. The chest was opened through a median sternotomy and the full-skeletonized right internal thoracic artery was grafted on the LAD without cardiopulmonary bypass. A transverse elliptical incision was made after the median sternotomy was closed, and the breast tumor and lymph nodes around the subclavian and axillary vessels were completely dissected. Even in the case of multiple vessel coronary disease, simultaneous surgery may be possible, but indications should be carefully assessed considering the cardiac function and general condition of the patient.

Simultaneous operation of ischemic heart disease, abdominal aortic aneurysm, and rectal cancer

A 68-year-old man with ischemic heart disease, abdominal aortic aneurysm, and rectal cancer was referred. Coronary angiography indicated triple-vessel disease with jeopardized collaterals, and dipyridamole myocardial scintigraphy disclosed no viability in the inferior, posterior, and lateral walls. Abdominal computed tomography scanning revealed an infrarenal abdominal aortic aneurysm, 65 mm in diameter, with an expanding rate of 8 mm/year. Barium enema revealed stenosis 4 cm in length 5 cm inward from the anal verge, and an endoscopic finding was ulcerated type tumor with a clear margin and circumferential stenosis. Histological examination of a biopsy specimen revealed adenocarcinoma, and the clinical stage in the Japanese classification of colorectal carcinoma was II according to other examinations. Simultaneous operations were scheduled because of the jeopardized collaterals of the coronary arteries, rapid expansion of the aneurysm, and subileus due to the cancer. The patient underwent simultaneous off-pump coronary artery bypass grafting to the left anterior descending artery with the in situ internal thoracic artery through a median sternotomy, abdominal aortic aneurysm repair with a tube graft through a median laparotomy, and the Miles' operation with total mesorectal excision. Although infection of the perineal wound was postoperatively recognized, it remained local and was healed with irrigation only. The patient is doing well 12 months after the operation, without myocardial ischemic symptoms or recurrence of the cancer.

Coronary artery bypass grafting in patient with malignant neoplasm. Efficacy of coronary artery bypass grafting on beating heart

OBJECTIVE

Coronary artery bypass grafting (CABG) prior to noncardiac major surgery has effectively decreases short- and long-term mortality related to coronary ischemia. Coronary artery bypass on the beating heart is conducted to avoid the risk of cardiopulmonary bypass and it has contribute to shorten recovery time.

METHODS

Subjects were 19 patients with malignant neoplasm for whom a retrospective chart review was made between Jan. 1, 1992 and July 31, 1998. In the early phase of this study, between Jan. 1, 1992, and Dec. 31, 1997, CABG was performed using cardiopulmonary bypass, and late phase, between Jan. 1, 1998, and July 1, 1998, CABG was done on the beating heart without cardiopulmonary bypass.

RESULTS

Conventional CABG was performed in 12 patients with neoplasms (10 male and 2 female, age 64.7 +/- 6.1 years), and CABG on the beating heart was performed in 7 patients (6 male and 1 female, age 68.0 +/- 7.5 years). Fewer number of bypass grafts were made in the beating-heart CABG group (1.3 +/- 0.5 in beating-heart CABG versus 3.9 +/- 1.1 in conventional CABG). No cardiac events occurred in either group during the surgery for malignant tumors. The operative interval between CABG and cancer surgery was significantly shorter in the beating-heart CABG group (21.8 +/- 17.9 days in beating-heart CABG versus 53.5 +/- 42.9 days in conventional CABG, p < 0.05).

CONCLUSION

Patients with severe coronary artery disease and malignant neoplasms should undergo coronary artery revascularization before the neoplasm is treated. CABG on the beating-heart was safe and effective procedure in those with malignant neoplasms.