Association of Robotic Totally Endoscopic Coronary Artery Bypass Graft Surgery Associated With a Preliminary Cardiac Enhanced Recovery After Surgery Program: A Retrospective Analysis

Impact of an enhanced recovery after surgery program integrating cardiopulmonary rehabilitation on post-operative prognosis of patients treated with CABG: protocol of the ERAS-CaRe randomized controlled trial

BACKGROUND

Coronary artery bypass grafting is associated with a high occurrence of postoperative cardiopulmonary complications. Preliminary evidence suggested that enhanced recovery after surgery can effectively reduce the occurrence of postoperative cardiopulmonary complications. However, enhanced recovery after surgery with systematic integration of cardiopulmonary rehabilitation (ERAS-CaRe) into for Coronary artery bypass grafting has not been evaluated so far. We thus design the ERAS-CaRe randomized-controlled trial to evaluate possible superiority of embedding cardiopulmonary rehabilitation in ERAS over ERAS alone as well as to investigate effects of differential timing of cardiopulmonary rehabilitation within enhanced recovery after surgery (pre-, post-, perio-operative) on post-operative cardiopulmonary complications following Coronary artery bypass grafting surgery.

METHODS

ERAS-CaRe is a pragmatic, randomized-controlled, parallel four-arm, clinical trial. Three hundred sixty patients scheduled for Coronary artery bypass grafting in two Chinese hospitals will be grouped randomly into (i) Standard enhanced recovery after surgery or (ii) pre-operative ERAS-CaRe or (iii) post-operative ERAS-CaRe or (iv) perio-operative ERAS-CaRe. Primary outcome is the occurrence of cardiopulmonary complications at 10 days after Coronary artery bypass grafting. Secondary outcomes include the occurrence of other individual complications including cardiac, pulmonary, stroke, acute kidney injury, gastrointestinal event, ICU delirium rate, reintubation rate, early drainage tube removal rate, unplanned revascularization rate, all-cause mortality, ICU readmission rate, plasma concentration of myocardial infarction-related key biomarkers etc. DISCUSSION: The trial is designed to evaluate the hypothesis that a cardiopulmonary rehabilitation based enhanced recovery after surgery program reduces the occurrence of cardiopulmonary complications following Coronary artery bypass grafting and to determine optimal timing of cardiopulmonary rehabilitation within enhanced recovery after surgery. The project will contribute to increasing the currently limited knowledge base in the field as well as devising clinical recommendations.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trials Registry on 25 August 2023 (ChiCTR2300075125; date recorded: 25/8/2023, https://www.chictr.org.cn/ ).

Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS)

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.

Minimally Invasive Direct Coronary Artery Bypass Grafting: Sixteen Years of Single-Center Experience

Background: Coronary artery disease is a major cause of death globally. Minimally invasive direct coronary artery bypass (MIDCAB), using a small left anterior thoracotomy, aims to provide a less invasive alternative to traditional procedures, potentially improving patient outcomes with reduced recovery times. Methods: This retrospective, non-randomized study analyzed 310 patients who underwent MIDCAB between July 1999 and April 2022. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Statistical analysis was conducted using IBM SPSS, with survival curves generated via the Kaplan-Meier method. Results: The cohort had a mean age of 63.3 ± 10.9 years, with 30.6% females. The majority of surgeries were elective (76.1%), with an average operating time of 129.7 ± 35.3 min. The median rate of intraoperative blood transfusions was 0.0 (CI 0.0-2.0) Units. The mean in-hospital stay was 8.7 ± 5.5 days, and the median ICU stay was just one day. Early postoperative complications were minimal, with a 0.64% in-hospital mortality rate. The 6-month and 1-year mortalities were 0.97%, with a 10-year survival rate of 94.3%. There were two cases of perioperative myocardial infarction and no instances of stroke or new onset dialysis. Conclusions: The MIDCAB approach demonstrates significant benefits in terms of patient recovery and long-term outcomes, offering a viable and effective alternative for patients suitable for less invasive procedures. Our results suggest that MIDCAB is a safe option with favorable survival rates, justifying its consideration in high-volume centers focused on minimally invasive techniques.

Association between improved compliance with enhanced recovery after cardiac surgery guidelines and postoperative outcomes: A retrospective study

OBJECTIVE

Enhanced recovery after cardiac surgery is a multidisciplinary clinical care pathway that relies on a bundle of interventions, aiming to reduce the stress response to surgery and promote early recovery of organ function. In 2011, our institution introduced an institutional enhanced recovery after cardiac surgery program focusing on 9 central interventions, which have been expanded during the past decade by additional interventions now considered standard of care. After the recent publication of the enhanced recovery after cardiac surgery guidelines, we evaluated the relation between the compliance with these enhanced recovery after cardiac surgery guidelines and postoperative outcomes.

METHODS

All patients enrolled in our enhanced recovery after cardiac surgery program in 2019 were included in this retrospective single-center audit. The primary outcome was compliance with 23 enhanced recovery after cardiac surgery guidelines. Secondary outcomes included occurrence of at least 1 postoperative complication and hospital length of stay.

RESULTS

A total of 356 patients were included in this study. Compliance with the enhanced recovery after cardiac surgery guidelines was 64%. Postoperatively, 51% of the patients experienced at least 1 complication and had a median hospital length of stay of 6 days. Multivariable analysis showed that an increased compliance (per 10%) with the enhanced recovery after cardiac surgery guidelines was associated with a lower risk for any complication (odds ratio, 0.60; 95% confidence interval, 0.46-0.79; P = .0003) and a higher probability of earlier hospital discharge (hazard ratio, 1.25; 95% confidence interval, 1.10-1.43; P = .0008).

CONCLUSIONS

This audit revealed a correlation between increased compliance with enhanced recovery after cardiac surgery guidelines and a reduction of postoperative complications and hospital length of stay. Future trials are needed to establish evidence-based recommendations for each separate intervention of the enhanced recovery after cardiac surgery guidelines and to create a minimum core-set of enhanced recovery after cardiac surgery interventions.

Intensive Care Unit Bypass for Robotic-Assisted Single-Vessel Coronary Artery Bypass Grafting

BACKGROUND

Fast-track and enhanced recovery after cardiac surgical procedures have shown reductions in intensive care unit (ICU) and hospital lengths of stay, with unchanged outcomes. However, cost reduction by an ultra-fast-track protocol after minimally invasive cardiac operations, without compromising clinical benefits, has yet to be demonstrated.

METHODS

A total of 215 consecutive patients underwent robotic-assisted coronary artery bypass grafting, with 156 preoperatively stratified into conventional ICU recovery vs 59 candidates for a defined ICU-bypass protocol involving recovery room and floor care. Of these, 40 candidates completed the protocol, and 19 had conversion-to-ICU recovery. Because of right-skewed distribution, inpatient cost was log-transformed, and linear regression models were constructed to estimate geometric mean ratios (GMRs) comparing inpatient cost for these groups (conventional ICU recovery, ICU-bypass, conversion-to-ICU recovery), adjusted for The Society of Thoracic Surgeons Predicted Risk of Mortality score.

RESULTS

Compared with the conventional ICU group, the ICU-bypass group conferred a 15% reduction in total inpatient (GMR, 0.85; P = .0007) and a 14% reduction in total variable direct costs (GMR, 0.86; P = .003). Compared with the conventional ICU group, the ICU-bypass and conversion-to-ICU groups had similar net hospital stay reductions (1.6-1.7 days). Relative to the conventional ICU group, ICU and floor duration were shortened after conversion to ICU, with a trend to reduced costs. Cardiac arrest, 30-day mortality, and stroke were absent, and other key adverse events did not differ between groups.

CONCLUSIONS

A selective, successful ultra-fast-track ICU-bypass protocol for robotic-assisted coronary artery bypass grafting reduces inpatient cost without affecting short-term outcomes. Conversion-to-ICU recovery also maintains outcomes and trends toward reduced costs.

The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study

OBJECTIVES

The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery.

DESIGN

A retrospective observational study.

SETTING

A single large teaching hospital.

PARTICIPANTS

A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data.

INTERVENTIONS

Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications.

MEASUREMENTS AND MAIN RESULTS

The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups.

CONCLUSIONS

Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

A Scientometric Analysis and Visualization Discovery of Enhanced Recovery After Surgery

Background

Enhanced recovery after surgery (ERAS), a new clinical surgical concept, has been applied in many surgical disciplines with good clinical results for the past 20 years. Bibliometric analysis is an effective method to quantitatively evaluate the academic productivity. This report aimed to perform a scientometric analysis of the ERAS research status and research hotspots.

Methods

Comprehensive scientific mapping analysis of a wide range of literature metadata using the scientometric tools, including the Bibliometrix R Package, Biblioshiny, and CiteSpace. Data were retrieved from the Web of Science Core Collection database of original articles from 2001 to 2020. Specific indicators and maps were analyzed to show the co-authorship, co-institute, co-country, co-citation, and international cooperation. Automatic literature screening, unsupervised cluster filtering, and topic cluster identification methods were used to display the conceptual framework and thematic evolution.

Results

A total of 1,403 research projects drafted by 6,966 authors and published in 413 sources were found. There was an exponential growth in the number of publications on ERAS. There were 709 collaborations between authors from different countries, and the US, China, and the UK had the greatest number of publications. The WORLD JOURNAL OF SURGERY, located in Bradford’s Law 1, had the highest number of published articles (n = 1,276; total citations = 3,193). CiteSpace network analysis revealed 15 highly correlated cluster ERAS studies, and the earliest study was on colonic surgery, and ERAS was recently applied in cardiac surgery. The etiology of ERAS is constantly evolving, with surgery and length of hospital as the main topics. Meta-analyses and perioperative care have tended to decline.

Conclusion

This is the first scientometric analysis of ERAS to provide descriptive quantitative indicators. This can provide a better understanding of how the field has evolved over the past 20 years, help identify research trends, and provide insights and research directions for academic researchers, policymakers, and medical practitioners who want to collaborate in these areas in the future.

Enhanced recovery after cardiac surgery and its impact on outcomes: A systematic review

BACKGROUND AND AIM

Enhanced Recovery After Surgery (ERAS) protocols are a series of perioperative interventions well-established in improving the care and outcomes of patients. With recent emergence of studies on its implementation in cardiac surgery, this paper represents the first systematic review on current evidence of ERAS efficacy in this field.

METHODS

Two reviewers independently searched through Pubmed, Cochrane, Google Scholar, Web of Science, Embase and Scopus. Comparative studies with controls that described the implementation of ERAS in all types of cardiac operations from 2001 to 2020 were included. Data extracted included patient demographics, components of ERAS protocol described, types of cardiac surgery, and postoperative outcomes.

RESULTS

In the final analysis, nine studies were included, of which there were one randomized controlled trial (RCT), one quasi-experiment and seven retrospective/prospective studies. Significant improvement in hospital and ICU length of stay, as well as reduction in postoperative opioid consumption were demonstrated. No increase in postoperative complications were reported.

CONCLUSION

ERAS in cardiac surgery has shown to be potentially safe and effective in improving certain postoperative outcomes. However, the evidence is limited by the lack of high-quality RCTs. We also found the lack of practice of class 1 recommended interventions set forth by the ERAS Cardiac Society. Furthermore, majority of studies only evaluated the immediate postoperative outcomes of patients, and not the long-term outcomes. RCTs that fully implement measures recommended by the ERAS Cardiac Society, with assessments on both immediate and long-term outcomes, are warranted.

Left atrial appendage occlusion in a mirror-image dextrocardia: A case report and review of literature

BACKGROUND

In mirror-image dextrocardia, the anterior-posterior position of the cardiac chambers and great vessels is maintained, but the left-right orientation of the abdominal organs is reversed. The abnormal anatomy of the heart poses surgical challenges and problems in dealing with surgical risk and monitoring complications. There are few reports on closure of the left atrial appendage (LAA) in dextrocardia and no reports on the application of enhanced recovery after surgery (ERAS) following LAA occlusion (LAAO) procedures.

CASE SUMMARY

The objective for this case was to ensure perioperative safety and accelerate postoperative recovery from LAAO in a patient with mirror-image dextrocardia. ERAS was guided by the theory and practice of nursing care. Atrial fibrillation was diagnosed in a 77-year-old male patient, in whom LAAO was performed. The 2019 guidelines for perioperative care after cardiac surgery recommend that the clinical nursing procedures for patients with LAAO should be optimized to reduce the incidence of perioperative complications and ensure patient safety. Music therapy can be used throughout perioperative treatment and nursing to improve the anxiety symptoms of patients.

CONCLUSION

The procedure was uneventful and proceeded without complications. Anxiety symptoms were improved.

Multi-Spectrum Robotic Cardiac Surgery: Early Outcomes

Objective

The robotic cardiac surgery program at our current institution began in 2013 with an experienced and dedicated team. This review analyzes early outcomes in the first 1103 patients.

Methods

We reviewed all robotic procedures between July 2013 and February 2021. Primary outcomes were mortality and perioperative morbidity. Our robotic approach is totally endoscopic for all cases: off-pump for coronary and epicardial procedures, and on-pump with the endoballoon for mitral valve and other intracardiac procedures.

Results

There were 1103 robotic-assisted cardiac surgeries over 7 years. A total of 585 (53%) were off-pump totally endoscopic coronary artery bypasses, 399 (36%) intracardiac cases (including isolated and concomitant mitral valve procedures, isolated tricuspid valve repair, CryoMaze, atrial or ventricular septal defect repair, benign cardiac tumor, septal myectomy, partial anomalous pulmonary venous drainage, and aortic valve replacement); 80 (7%) epicardial electrophysiology-related procedures (epicardial atrial fibrillation ablation, left atrial appendage ligation, lead placement, and ventricular tachycardia ablation); and 39 (4%) other epicardial procedures (pericardiectomy, unroofing myocardial bridge). Mortality was 1.2% (observed/expected ratio, 0.7). In the totally endoscopic coronary artery bypass and intracardiac groups, mortality was 1.0% (observed/expected, 0.6) and 1.5% (observed/expected, 0.87), respectively. There were 8 conversions to sternotomy (0.7%) and 24 (2.2%) take-backs for bleeding. Mean hospital and intensive care unit lengths of stay were 2.74 ± 1.26 days and 1.28 ± 0.57 days, respectively.

Conclusions

This experience demonstrates that a robotic endoscopic approach can safely be used in a multitude of cardiac surgical procedures both on- and off-pump with excellent early outcomes. An experienced surgeon and team are necessary. Longer-term follow-up is warranted.

Robotic off-pump totally endoscopic coronary artery bypass in the current era: report of 544 patients

OBJECTIVES

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years.

METHODS

Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization.

RESULTS

The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%.

CONCLUSIONS

We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

Minimally invasive and robotic coronary artery bypass grafting-a 25-year review

During the mid-1990s cardiac surgery started exploring minimally invasive methods for coronary artery bypass grafting (CABG) and has over a 25-year period developed highly differentiated and less traumatic operations. Instead of the traditional sternotomy mini-incisions on the chest or ports are placed, surgery on the beating heart is applied, sophisticated remote access heart lung machine systems as well as videoscopic units are available, and robotic technology enables completely endoscopic approaches. This review describes these methods, reports on the cumulative intra- and postoperative outcome of these procedures, and gives an integrated view on what less invasive coronary bypass surgery can achieve. A total of 74 patient series published on the topic between 1996 and 2019 were reviewed. Six main versions of minimal access and robotically assisted CABG were applied in 11,135 patients. On average 1.3±0.6 grafts were placed and the operative time was 3 hours 42 min ± 1 hour 15 min. The procedures were carried out with a hospital mortality of 1.0% and a stroke rate of 0.6%. The revision rate for bleeding was 2.5% and a renal failure rate of 0.9% was noted. Wound infections occurred at a rate of 1.2% and postoperative hospital stay was 5.6±2.2 days. It can be concluded that less invasive and robotically assisted versions of coronary bypass grafting are carried out with an adequate safety level while surgical trauma is significantly reduced.

Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review

OBJECTIVES

Use of minimally invasive cardiac surgery (MICS) is increasing, but to exert its maximum effect on patient outcomes, MICS must be coupled with improved perioperative management, including the Enhanced Recovery after Surgery (ERAS) and fast-track protocols. This study aimed to evaluate the impact of ERAS and fast track in this context.

DESIGN

NARRATIVE REVIEW: The authors performed a narrative review that included patients treated with MICS and patients treated with the ERAS/fast-track protocols in the MEDLINE/PubMed database. The keywords ERAS and fast-track were combined with the following key words: minimally invasive cardiac surgery OR robotic cardiac surgery OR minimally invasive mitral surgery OR minimally invasive aortic surgery.

RESULTS

Overall, the authors selected six studies in which either the ERAS or fast-track protocol was applied. The reported adherence to ERAS protocols was high, and neither protocol-related complications nor in-hospital mortality occurred. Patients managed based on ERAS had significantly lower postoperative pain scores, fewer rates of blood transfusions, and shorter hospital and intensive care unit stays compared with those who received standard management. All ERAS patients were managed safely, with early extubation. Similarly, fast-track cardiac surgery, with immediate postprocedure extubation and early transfer to the ward, was shown to be safe, with no increased morbidity or mortality.

CONCLUSION

Use of standardized ERAS and fast-track protocols seems to be feasible and safe in the context of MICS, with improved outcomes. Both ERAS and fast track allow for a faster return to full functional status while minimizing perioperative complications.

Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review

Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.

Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies

BACKGROUND

Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease.

METHODS

We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate.

RESULTS

We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small.

CONCLUSION

Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

Orthopedic Principles to Facilitate Enhanced Recovery After Cardiac Surgery

Enhanced recovery after surgery (ERAS) protocols recognize early postoperative mobilization as a driver of faster postoperative recovery, return to normal activities, and improved long-term patient outcomes. For patients undergoing open cardiac surgery, an opportunity for facilitating earlier mobilization and a return to normal activity lies in the use of improved techniques to stabilize the sternal osteotomy. By following the key orthopedic principles of approximation, compression, and rigid fixation, a more nuanced approach to sternal precaution protocols is possible, which may enable earlier patient mobilization, physical rehabilitation, and recovery.

Application of tissue-engineered interventions for coronary artery bypass grafts

Coronary artery bypass graft is one of the extensively conducted procedures to release occlusion in the coronary vessel. Various biological grafts are used for this purpose, superiorly, saphenous vein graft, if unavailable, other vessels in the body, with likewise characteristics are exploited for the purpose. The choice of graft is yet under discovery that could impeccably meet all the requirements. Variation in perioperative and postoperative results have given uneven clinical inferences of these conduits. Alternatively, tissue-engineering is also being applied in this area for clinical improvements. This review underlines some of the commonly used grafts for coronary artery bypass graft and advancements in tissue engineering for this purpose.

Robotic totally endoscopic coronary artery bypass grafting: current status and future prospects

Introduction: Totally endoscopic coronary artery bypass grafting (TECAB) can only be performed in a reproducible manner using robotic technology. This operation has been developed for more than 20 years seeing three generations of surgical robots. TECAB can be carried out beating heart but also on the arrested heart. Single and multiple grafts can be placed and TECAB can be combined with percutaneous coronary intervention in hybrid procedures.Areas covered: This review outlines indications for the procedure, the surgical technique, and the postoperative care. Intra- and postoperative results as available in the literature are reported. Further areas focus on technological development, training methods, learning curves as well as on cost. Finally, we give an outlook on the potential future of this operation.Expert opinion: Robotic TECAB represents a complex, sophisticated but safe, and over-the-years grown procedure. Even though results seem to be in line with conventional coronary surgery worldwide adoption still has been slow probably due to procedure times, costs and learning curves. Main advantages of TECAB are minimized surgical trauma and subsequent reduction of postoperative healing time. With the current introduction of new robotic devices, a new era of procedure development is on its way.

Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Systematic Review of Clinical Outcomes from the Past two Decades

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

Robotic lymphadenectomy of an internal mammary lymph node metastasis

A 58-year-old woman was diagnosed with a left-sided lone internal mammary swollen lymph node on a routine follow-up computer tomography, 42 months after a left mastectomy in the context of a ductal carcinoma grade III. The suspected metastasis was successfully removed in toto using a 3-port-da Vinci robotic procedure and the patient was discharged home without any complication on the third postoperative day. Robotically assisted oncological lymph node removal is safe, easily performed and economically affordable.

Is robotic beating heart totally endoscopic coronary artery bypass feasible for BMI > 35 morbidly obese patients?

BACKGROUND

We investigated the outcomes of morbidly obese patients after robotic beating heart totally endoscopic coronary artery bypass (BH-TECAB).

METHODS

This is a retrospective single center study. From July 2013 to December 2016, the outcomes of patients undergoing BH-TECAB were reviewed.

RESULTS

A total of 234 patients underwent BH-TECAB (172 male, mean age 65.2 years). There were 43 morbidly obese patients defined as body mass index (BMI) greater than 35, and 191 non-morbidly obese patients. Postoperative complications, or mortality in morbidly obese and other patients were similar except for prolonged ventilation >24 h (11.6% vs 2.1%, P = 0.008).

CONCLUSIONS

Morbidly obese patients had an increased incidence of prolonged ventilation after BH-TECAB, but an otherwise reasonably low morbidity and mortality similar to patients with a lower BMI. We believe that adoption of robotics technology allows for BH-TECAB and can lead to improved outcomes in this high-risk population.

A systematic review on robotic coronary artery bypass graft surgery

BACKGROUND

Robotic-assisted coronary artery bypass graft surgery (CABG) has been performed over the past decade. Despite encouraging results from selected centres, there is a paucity of robust clinical data to establish its clinical safety and efficacy. The present systematic review aimed to identify all relevant clinical data on robotic CABG. The primary endpoint was perioperative mortality, and secondary endpoints included perioperative morbidities, anastomotic complications, and long-term survival.

METHODS

Electronic searches were performed using three online databases from their dates of inception to 2016. Relevant studies fulfilling the predefined search criteria were categorized according to surgical techniques as (I) totally endoscopic coronary artery bypass without cardiopulmonary bypass (TECAB off-pump); (II) TECAB on-pump; and robotic-assisted mammary artery harvesting followed by minimally invasive direct coronary artery bypass (robotic MIDCAB).

RESULTS

The present systematic review identified 44 studies that fulfilled the study selection criteria, including nine studies in the TECAB off-pump group and 16 studies in the robotic MIDCAB group. Statistical analysis reported a pooled mortality of 1.7% for the TECAB off-pump group and 1.0% for the robotic MIDCAB group. Intraoperative details such as the number and location of grafts performed, operative times and conversion rates, as well as postoperative secondary endpoints such as morbidities, anastomotic complications and long-term outcomes were also summarized for both techniques.

CONCLUSIONS

A number of technical, logistic and cost-related issues continue to hinder the popularization of the robotic CABG procedure. Current clinical evidence is limited by a lack of randomized controlled trials, heterogeneous definition of techniques and complications, as well as a lack of robust clinical follow-up with routine angiography. Nonetheless, the present systematic review reported acceptable perioperative mortality rates for selected patients at specialized centres. These results should be considered as a useful benchmark for future studies, until further data is reported in the form of randomized trials.

Perioperative application of enhanced recovery after surgery in biliary tract surgery

AIM

To evaluate the safety and clinical effects of enhanced recovery after surgery (ERAS) in the perioperative period of biliary tract surgery.

METHODS

Clinical data for patients who underwent selective biliary surgery at Department of Hepatobiliary Surgery, Affiliated Hospital of Binzhou Medical University from October 2014 to April 2016 were collected. The patients were divided into either a control group (n = 312) to receive traditional perioperative management or an ERAS group (n = 304) to receive fast-track surgical intervention. Each group was divided into subgroups according to the different operative methods used (laparoscopic cholecystectomy, common bile duct exploration and drainage, and cholangioenterostomy) and compared. The differences in preoperative fasting time, indwelling rate and duration of gastric tube and catheter, indwelling duration of abdominal cavity drainage tube, T tube cholangiography time, continuous postoperative ECG monitoring time, postoperative opioid drug use rate, postoperative complications rate, time to first postoperative ambulation, time to first postoperative exhaust, length of hospital stay, and hospitalization expenses as well as the readmission rate and mortality during 30 d after discharge between groups were compared.

RESULTS

Compared with the control group, the ERAS group had significantly shortened preoperative fasting time, decreased indwelling rates of gastrointestinal decompression tube and catheter, shortened indwelling durations of gastrointestinal decompression tube, catheter, and peritoneal cavity drainage tube, shortened time for postoperative T tube cholangiography and duration of postoperative continuous ECG monitoring, decreased postoperative opioid drug use rate, shortened time to postoperative ambulation and exhaust, decreased incidence of postoperative complications, shortened total hospital stay and postoperative hospitalization time, and decreased hospitalization expenses (P < 0.05). No readmission or death was found during 30 d after discharge.

CONCLUSION

The application of ERAS concept and measures in the perioperative period of biliary tract surgery reduces postoperative pain, accelerates the recovery of gastrointestinal function, promotes postoperative early ambulation, reduces the incidence of postoperative complications, shortens hospital stay, decreases the cost of hospitalization, and enhances the early recovery of the patients.

A Single Surgeons Experience with Enhanced Recovery after Surgery: An Army of One

The benefits of enhanced recovery after surgery (ERAS) have been demonstrated for multiple surgical procedures in high-volume programs. However, resources required for its implementation may be daunting to individual surgeons. Patients undergoing elective abdominal procedures from June 2013 to April 2015 by a surgical oncologist before and after the implementation of an ERAS protocol were reviewed. A total of 179 patients were included. The mean age of the patients was 63 years, and a majority of them were females (53.6%), white (61.5%), had a Charlson score of 0 to 2 (45.8%), and a Clavien complication grade of 0 to I (60.1%). The univariate analysis revealed that the ERAS protocol was associated with shorter length of stay (LOS) (6.2 vs 9.6 days), lower cost ($21,674 vs $30,380), and lower mortality (0 vs 3.3%); P < 0.05. Differences were noted in LOS and costs for all procedures, the differences were the greatest for hepatic resection (3.8 vs 8.4 days and $16,770 vs $28,589), intestinal resection/stoma closure (4.8 vs 7.6 days and $18,391 vs $22,239), and other abdominal procedures (5.0 vs 10.8 and $17,713 vs $30,900); P < 0.05. The differences were less for patients undergoing procedures for which postoperative pathways were already in place such as pancreatic (9 vs 10.8 days and $30,524 vs $34,291) and colorectal (5.3 vs 6.5 days and $20,733 vs $25,150) surgeries. P > 0.05. An ERAS program can be instituted by an individual surgeon with the benefits of decreased LOS, cost, and mortality.