Summary
In the peri-operative and post-operative course of coronary bypass operations, the diabetic patient is susceptible to complications that cause morbidity and mortality. Morbidity might best be conceptualized as the cumulative effect of the diabetic patient chronically at risk and a variety of surgically related insults, including surgical stress, anaesthesia, hypo- and hypertension, anaemia, dysrhythmias, de- or hyperhydration and cardiopulmonary bypass (CPB) that exceed the compensatory capacities of the patient. Because all these factors for adverse outcome coexist, it becomes difficult to determine which ones are most important. However, it is reasonable that, in the presence of generalized atherosclerosis affecting the aorta ascendens, carotids and the cerebral arteries, the interaction of CPB-associated embolization, hypoperfusion and inflammation may cause neurologic morbidity. Many physiologic alterations (such as non-pulsatile perfusion and hemodilution) occur during CPB and may worsen renal dysfunction in patients with diabetic nephropathy. Pulmonary dysfunctions, associated with diabetic microangiopathy, could be unmasked by atelectasis, capillary leak and other pathophysiological conditions developing after the use of extracorporeal circulation. Actually, there is evidence that with the avoidance of CBP and the use of adequate OPCAB (Off Pump Coronary Artery Bypass) techniques, by experienced teams, the incidences of neurological, renal and pulmonary complications decrease, in high-risk patients, e. g. diabetics, as well as in unselected cohorts. Because it is not possible to identify confidently those patients who are at risk for CPB-associated complications, we use a strategy where all CABG (Coronary Artery Bypass Grafting) are performed in OPCAB technique. The total OPCAB approach will in addition ascertain the development of organizational OPCAB routines and expertise. The process of re-engineering the unit towards total OPCAB needs systematic training and re-training of cardiac surgeons by surgeons, experienced in both, OPCAB surgery and knowledge transfer, according to the principles of continuing medical education (CME). Thus, the chances of the OPCAB technique improving the outcome of diabetic patients can be fully realized.
Zusammenfassung
Diabetiker sind besonders anfällig für das operative Trauma der Bypassoperation, welches neben vielen anderen iatrogenen Einwirkungen die Nebenwirkungen der Herz-Lungen-Maschine (HLM) und des kardioplegischen Herzstillstands umfasst. Die Risiken HLM-assoziierter Komplikationen sind bei Vorliegen der charakteristischen Begleit- oder Folgeerkrankungen des Diabetes, wie einer generalisierten Atherosklerose mit Befall der Aorta ascendens, den Karotiden oder intrazerebraler Gefäße, bei diabetischer Nephropathie oder pulmonalen Vorschädigungen, besonders groß. Das Vermeiden der HLM durch das OPCAB-Verfahren, ergab bessere Operationsergebnisse bei diesen Hochrisikopatienten aber auch in nichtselektierten Patientengruppen, wenn die Operationen von erfahrenen Teams ausgeführt wurden (www.ctsnet.org). Die Schwierigkeiten, die Risikokollektive zuverlässig zu bestimmen, und das Faktum, dass bestimmte Risikokonstellationen in der täglichen Praxis nicht identifiziert werden (z. B. erhält nicht jeder Patient vor der Bypassoperation ein TEE zum Ausschluss einer Atheromatose der Aorta ascendens), legen es nahe, bei allen Bypassoperationen die HLM zu vermeiden und das OPCAB-Verfahren anzuwenden. Eine solche Strategie lässt die OPCAB-Chirurgie zur täglichen Routine werden und fördert so die Ausbildung von Erfahrung und Expertise des gesamten Teams. Die Umstellung von der On-pump-Chirurgie zur Off-pump-Chirurgie bedarf eines systematischen Trainings, welches von Chirurgen durchgeführt werden sollte, die sowohl in der OPCAB-Technik als auch in CMEST (Continuing medical Education of Surgical techniques) geübt sind.
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Albert, A., Ennker, J. & Sergeant, P. Bypassoperationen bei Diabetikern—. Clin Res Cardiol 95 (Suppl 1), i40–i47 (2006). https://doi.org/10.1007/s00392-006-1109-9
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DOI: https://doi.org/10.1007/s00392-006-1109-9