Dhaliwal Rs

Role of physiological lung exclusion in difficult lung resections for massive hemoptysis and other problems

OBJECTIVES Pulmonary tuberculosis and bronchiectasis are the major causes of massive hemoptysis in developing countries. Lung resection remains the surgical treatment of choice. This may not always be possible and may even be hazardous in some patients due to fibrosis and dense vascular adhesions between the lung and the chest wall. This leads to marked blood loss and control of hilar vessels becomes dangerous. METHODS A series of 20 cases is described here. Nineteen presented with massive hemoptysis where control of bleeding was obtained by physiological lung exclusion. One patient had traumatic left main bronchus transection not suitable for repair or resection. Physiological lung exclusion was performed by surgical interruption of the bronchus and pulmonary artery of the involved lobe or lung, keeping pulmonary veins intact. RESULTS Hemoptysis could be controlled in all these patients without any significant morbidity. There was no mortality. There was no postoperative empyema and recurrence of hemoptysis on long-term follow-up. No patient required anatomical lung resection later on. CONCLUSIONS Physiological lung exclusion is a safe and effective method for control of massive hemoptysis in cases where lung resection is technically hazardous or difficult. This should be kept as an alternative or adjunct to anatomical lung resection.

Traumatic giant pseudoaneurysm of innominate artery.

A 20-year-old man developed a giant pseudoaneurysm of the innominate artery 5 months after blunt chest trauma, causing severe respiratory distress and superior vena cava compression symptoms. The patient was managed with hypothermia and low flow cardiopulmonary bypass resulting in a successful outcome.

Thymectomy for Myasthenia Gravis: 12-Year Experience

Thymectomy has been shown to be effective in the treatment of myasthenia gravis. The logical goal of operation is the complete removal of the thymus, but there is no consensus on the selection criteria of patients for surgery and the choice of surgical approach. We retrospectively reviewed 56 patients with myasthenia gravis who had been treated surgically by transsternal radical thymectomy between January 1990 and March 2002. The patients were symptomatically grouped according to the modified Osserman clinical classification. There was 1 hospital death, and 53 patients had been followed up for between 1 month and 12 years. Improvement after thymectomy was observed in 1 of 4 patients (25%) in Osserman group I, 25 of 34 patients (74%) in Osserman group IIA, and 16 of 18 patients (89%) in combined Osserman groups IIB and IIC. Transsternal radical thymectomy is an effective therapy for myasthenia gravis. Sustained improvement is achievable in female patients with moderate to severe symptoms and in patients with thymic hyperplasia.

Geographical variations in the presentation of ruptured aneurysms of sinuses of valsalva: evaluation of surgical repair.

From 1981 to 1992, 13 male and 7 female patients underwent surgical correction for ruptured aneurysms of sinus of valsalva. A total surgical experience of 22 procedures including 2 reoperations is presented, accounting for 1.37% of open heart surgery for congenital heart disease at PGIMER Chandigarh. Ninty percent were in the 20‐to 40‐year age group. Forty‐five percent of patients had symptoms of > 1‐year duration (range 2 months to 20 years) and catastrophic onset of symptoms was noted in four (18%). All patients had localized aneurysms originating either in right coronary sinus (14 pts) or noncoronary sinus (8 pts). Sites of origin and rupture are detailed. Associated congenital abnormalities such as ventricular septal defect (VSD) (13 pts), aortic regurgitation (3 pts), and left superior vena cava and atrial septal defect (ASD) (1 pt each) were noted. The data pertaining to Oriental and Western groups of patients were analyzed, and the differences in age, mode of presentation, site of origin, rupture, and the spectrum of associated abnormalities were elucidated. The majority of the patients (86.4%) were operated by the Bicameral approach. Repair was tailored according to the extent and severity of the defect in the sinus of Valsalva and aortic valve annulus and also the presence and site of VSD.

Early changes in pulmonary functions after mitral valve replacement.

BACKGROUND This study evaluates changes in pulmonary functions before and after mitral valve replacement (MVR). MATERIALS AND METHODS Twenty-five patients with rheumatic mitral lesions who had undergone MVR were divided into three groups, based on New York Heart Association (NYHA) class. They were evaluated for changes in pulmonary functions, preoperatively and postoperatively at 1 week, 1 month and 3 months to find any improvements after MVR. RESULTS Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rates were universally found to be decreased preoperatively. Total lung capacity (TLC) and diffusion capacity (DLCO) were significantly reduced preoperatively in NYHA Class III and IV. The pulmonary functions further declined at 1 week after surgery. Except for FVC in NYHA Class IV (32.3% improvement, P < 0.05), the changes were statistically insignificant. CONCLUSIONS Pulmonary functions deteriorate immediately after surgery and then recover gradually over a period of 3 months. However, they remain below the predicted values.

Posterior Mediastinal Goiters: Literature Review and Report of Three Cases

Posterior mediastinal goiters are very rare and occur mostly due to descent of a posterolaterally enlarging inferior pole of the thyroid gland, or very infrequently to failure of fusion of the ultimobranchial bodies with the isthmus in the 7th embryonic week. Most patients present with a cervical mass and symptoms due to compression or distortion of the trachea, esophagus, or superior vena cava. The diagnosis is established by chest skiagram, computed tomography scan, and barium esophagogram. Progressive enlargement, risk of sudden hemorrhage within the gland causing respiratory impairment, and the possibility of associated malignancy, make excision of the goiter mandatory. A combined cervicothoracic approach is the procedure of choice as it provides easy access and visualization, better control of blood vessels, and avoids the risk of perioperative tumor seeding. We present our experience of 3 such cases successfully managed at our institute. All 3 patients presented with a cervical mass and symptoms of posterior mediastinal compression; one had thyrotoxicosis. A combined cervicothoracic approach was used for surgical excision with excellent results.

Traumatic sternocostal lung hernia

We report the case of a 6‐year‐old child who fell from a height of almost 10 metres. He had a large wound in the anterior chest wall with herniation of the lung through a defect produced by dysjunction of costo‐chondral/sterno‐chondral cartilages of the second to the fifth right ribs. Successful reduction and surgical repair was performed through a right anterolateral thoracotomy.

Recurrent left atrial myxoma presenting as peripheral arterial embolus

Recurrence of left atrial myxoma is rare. A male aged 18 years developed recurrence of left atrial myxoma despite excision of the tumour along with an ample cuff of the atrial septum around the tumour stalk, two years earlier. The patient presented with peripheral arterial embolus and underwent right femoropopliteal embolectomy and excision of the recurrent atrial myxoma. The presentation of recurrent left atrial myxoma with peripheral arterial embolism has perhaps not been reported earlier. Etiopathology of recurrence of myxomas and surgical treatment are discussed.

The Transseptal T-Cut—What More Can We See?

Abstract  An optimal approach to the mitral valve for repair or replacement must provide adequate exposure even in a small left atrial and redo cases, without need for forceful retraction. This benefit of good exposure must not be at the cost of increased morbidity from increased postoperative bleeding, SA node, or atrioventricular node dysfunction. We describe a simple technique of transseptal T‐cut for exposure of the mitral valve, which is without the attendant complications of the other techniques.

Emergency closed mitral valvotomy with transesophageal echocardiographic guidance.

For reprint information contact: Harkant Singh, MCh Tel: 91 981 507 5294 Email: baryah@gmail.com Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Sciences and Research, Sector 12, Chandigarh 160012, India. A 25-year-old patient with mitral stenosis presented in acute pulmonary odema after a failed balloon mitral valvotomy. She underwent a successful emergency closed mitral valvotomy (CMV) through a quick limited anterolateral thoracotomy with cardiopulmonary bypass on standby.