Beating-heart totally endoscopic coronary artery bypass grafting: report of a case

A systematic review of the safety and efficacy of distal coronary artery anastomotic devices in MIDCAB and TECAB surgery

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) techniques may improve recovery and reduce hospital stay following coronary artery bypass surgery (CABG). However, working in a limited space with indirect visualisation would greatly benefit from a simple, high-quality and reproducible automated distal anastomotic method. Several devices have been developed; however, their uptake has been limited due to uncertainty around their impact on patient outcomes.

METHODS

A systematic review of the literature identified six studies, incorporating 139 subjects undergoing MIDCAB or TECAB surgery using a distal anastomotic device.

RESULTS

The overall 30-day mortality was 0.7% (1/137). No cardiac specific mortality was observed. For each outcome of perioperative myocardial infarction (MI), postoperative stroke and haemorrhage, only a single event was observed for each (n=1/136, 1/138 and 1/136, respectively). The overall device failure rates were low, with the use of additional sutures only reported in a single case with the Magnetic Vascular Port (MVP) device. Anastomotic time ranged from a mean of 3.32 minutes with the MVP device to 20 minutes with the C-Port device.

CONCLUSIONS

These results demonstrate the overall acceptable early outcomes of distal anastomotic devices for use in minimally invasive coronary bypass surgery. Future research should focus on designing adequately powered, comparative, randomised trials, focusing on major adverse cardiac and cerebrovascular events (MACCE) outcomes in both the short and long-term, with clear case-by-case reasons for device failure and a comparison of anastomotic times. In this way, we may determine whether such devices will facilitate the minimal access and robotic coronary procedures of the future.

A systematic review of the safety and efficacy of distal coronary artery anastomotic devices

Interest in minimally invasive and off-pump cardiac surgical techniques has promoted the development of automated distal anastomotic devices (DADs) to facilitate construction of coronary artery anastomosis. Several DADs have been proposed for potential use in coronary surgery. However, a number of technical failures and uncertainty around both short-term morbidity and long-term patency have limited the generalized uptake of these devices. A systematic literature search identified 28 studies, incorporating 970 patients who underwent coronary artery bypass grafting using a DAD. Eight different devices were identified including Heartflo, St Jude, U-clip, vessel closure system, C-port, magnetic vascular positioner and coronary anastomosis coupler. Thirty-day mortality, cardiac-specific mortality and myocardial infarction were equal between DADs and hand-sewn cases (1.3, 0.3 and 0.8%, respectively). The overall proportion of postoperative haemorrhage was higher in the anastomotic device group (2.3%) than in the group with hand-sewn anastomoses (1.5%) although not statistically significant. Overall graft patency was 97.2% at <1 month, 94.6% at 1-3 months and 92.3% at >3 months. Of the currently available systems, the U-clip device was found to provide the best overall postoperative outcomes, which included a patency of 96.1% at >3months. The current literature is limited by its predominantly observational study design and lack of directly comparative studies. Furthermore, inter-study variation in patient selection, anticoagulation strategies and follow-up periods prevents quantitative comparison. Future research necessitates multicentre randomized, controlled studies to provide a direct comparison of current and future anastomotic device systems with established hand-sewn techniques in both the short and long term.

Single-incision laparoscopic Heller myotomy and Dor fundoplication for achalasia: report of a case

Our objective was to establish the efficiency of single-incision laparoscopic Heller myotomy and Dor fundoplication (SILHD) as treatment for esophageal achalasia. A 58-year-old man underwent SILHD for achalasia. The left triangular ligament was retracted using a suture thread and fixed to the body surface, providing a good operative field at the cardia. We performed a 7-cm long myotomy, extending 2 cm into the gastric wall, using a tissue-sealing device or L-shaped electrocautery. Oral intake resumed on postoperative day 1, and hospital stay was 4 days. No morbidity was observed. Based on our experience, we believe that the SILHD can be performed safely and seems to offer at least short-term benefits for selected patients with esophageal achalasia, when performed by surgeons experienced in laparoscopic and esophageal surgery.