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Biomedical subjects

E A Tovar

Publications and source records attributed to E A Tovar.

At least 19 recordsLinked to original sources
PubMed2001

Stapling of an aortic arch aneurysm.

Saccular aneurysms of the aortic arch are usually managed with patch graft aortoplasty or with tube graft replacement. In either case, hypothermic circulatory arrest is necessary. The use of stapling devices has revolutionized pulmonary and gastrointestinal surgery; however, these instruments have rarely been used in aortic surgery except during thromboexclusion procedures. We present a simple and seemingly innovative stapling method that eliminates the need for circulatory arrest.

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PubMed2001

One-day admission for major lung resections in septuagenarians and octogenarians: a comparative study with a younger cohort.

OBJECTIVES: The proportion of elderly patients presenting with a potentially resectable lung malignancy is increasing. Due to their greater operative risk, these patients are frequently offered a lesser resection, non-surgical treatment, or no treatment at all. The goal of this study is to determine whether septuagenarians and octogenarians undergoing video-assisted major lung resections benefit from an accelerated recovery program as much as younger patients, enabling them to be discharged after an overnight hospital stay. A short length of hospital stay, per se, does not represent the actual goal of this clinical care pathway. Instead, it should be considered as a measurement of how quickly functional ability is restored. METHODS: Of 65 consecutive patients who underwent major lung resections, 30 were 70 years of age or older (25 septuagenarians and five octogenarians; mean age, 75.7 years). Forty-six lobectomies, eight bilobectomies, and 11 pneumonectomies were performed using a video-assisted muscle-sparing minithoracotomy. In the elderly group, 24 lobectomies, three bilobectomies, and three pneumonectomies were performed. Patient and family education, multimodal analgesia, and an accelerated recovery program were implemented for all patients and the results were compared between the elderly group and the younger cohort. Discharge criteria included: (a), pain controlled with oral analgesics; (b), clear lungs in chest radiograph and without evidence of pneumothorax with the chest tube off suction; (c), independent ambulation; (d), adequate oxygenation; and (e), patient's acceptance and with home support. Whenever these criteria were met, regardless of how early or late during the hospital stay, the patient was released from the hospital. RESULTS: There were no deaths within 30 days of the operation and only three complications (one in the elderly group), and none of them altered the patients' clinical courses. The mean length of hospital stay for the whole group was 1.2 days (54 patients had an overnight hospital stay and two were outpatient procedures). The mean length of hospital stay for the elderly group was 1 day (27 patients had an overnight hospital stay and one was an outpatient procedure). None of the patients required conversion to a standard posterolateral thoracotomy and no patient required readmission related to an early discharge. CONCLUSIONS: These data show that it is feasible to create strategies to prevent or attenuate physiological derangements during surgery while performing major lung resections. As a result, an early recovery with few complications has been attained, allowing patients to consistently meet stringent discharge criteria after only an overnight hospital stay, even in the case of septuagenarians and octogenarians.

Adult↗
PubMed1999

Extrathoracic subclavian internal thoracic artery bypass grafting.

Interval development of a significant stenosis at the origin of the left internal thoracic artery (LITA) after this vessel has been used to revascularize the anterior descending coronary artery may be an indication for reoperation. We present an extrathoracic approach to bypass the proximal segment of the LITA that allows patients with this lesion a quick recovery, short hospital stay, and early resumption of normal activity.

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PubMed1998

Minimally invasive approach for pneumonectomy culminating in an outpatient procedure.

STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure.

Adult↗
PubMed1998

One-day admission for lung lobectomy: an incidental result of a clinical pathway.

BACKGROUND: Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained. METHODS: Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia. RESULTS: All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome. CONCLUSIONS: We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.

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PubMed1998

Muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia: an improved method for major lung resections.

To decrease incisional pain, morbidity, and length of hospital stay (LOS) and, hopefully, to reduce costs, most surgical specialties have turned to minimally invasive procedures to access the body cavities during commonly performed operations. Video-assisted thoracic surgery (VATS) has emerged as the standard approach for a number of diagnostic and therapeutic procedures in thoracic surgery. Major lung resections (lobectomy, bilobectomy, and pneumonectomy), however, can be performed through an incision similar in size to the utility or access thoracotomy used in VATS to remove the specimen. The purpose of this study was to compare an oblique muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia with the standard posterolateral thoracotomy incision and VATS to perform major lung resections. Forty consecutive patients with bronchogenic carcinoma, operated on by a single surgeon, were chronologically divided into two groups, each with equivalent age, sex distribution, physiologic parameters, tumor size, and clinical stage. In addition, data were collected from a MEDLINE search of all published studies in which major lung resections were performed via VATS. The first group (group A, n = 20) underwent posterolateral thoracotomy to access the chest cavity, whereas the patients in the second group (group B, n = 20) underwent oblique minithoracotomy with intercostal nerve cryoanalgesia. Group B compared favorably with group A in LOS (P = 0.002), narcotic requirements (P = 0.001), morbidity (P = 0.042), and cost (P = 0.058). Group B also compared favorably with VATS major lung resection published data regarding LOS and morbidity.

Adult↗
PubMed1997

Effects of surgical manipulation on coronary stents: should surgical strategy be altered?

BACKGROUND: Coronary artery bypass grafting is usually indicated for those patients who undergo open heart surgical procedures who have previously undergone percutaneous transluminal coronary angioplasty regardless of the absence of stenosis. Occasionally, however, if the treated artery has remained patent for many years and there is a shortage of conduit material or the patient is undergoing a complex operation, the branch is left ungrafted. With the gaining popularity of coronary stent placement, patients with these devices are undergoing open heart operations with increasing frequency. METHODS: To determine whether normal surgical manipulation during open heart surgical procedures results in obliteration of the Palmaz-Schatz stents previously deployed in the epicardial arteries, we developed an experimental model using ten isolated adult pig hearts. This allowed us to perform stent deployment and surgical manipulation and to apply direct pressure on the stented areas, with each heart evaluated by angioscopy and angiography and, finally, stent explantation. RESULTS: Retraction of the heart resulted in severe deformity of all left anterior descending artery stents, mild deformity of those in the circumflex artery, and mild or no deformity of those in the right coronary artery. However, direct pressure over the stented epicardial arteries (enough to retract the heart) resulted in complete obliteration of every intracoronary stent. CONCLUSIONS: The findings from this study indicate that once the need for surgical revascularization arises, a previously stented coronary artery should be bypassed even if the angiographic findings are normal, because of the likelihood that manipulation during an open heart operation will result in significant deformity or obliteration of the stent.

Angioscopy↗
PubMed1997

Severe deformity of a Palmaz-Schatz stent after normal surgical manipulation.

This report describes a case in which normal surgical manipulation during dissection of the heart while performing a repeat revascularization procedure produced a significant deformity in Palmaz-Schatz stents previously implanted in a saphenous vein graft. The graft had shown satisfactory angiographic appearance immediately before the operation, and consideration was given to leaving it in place. Its replacement, however, prevented a major intraoperative mishap.

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