Mohd Ramzisham Abdul Rahman

Chest Tube Injury to Left Ventricle: Complication or Negligence?

An injury to the left ventricle after a chest tube insertion is a rare but lethal phenomenon that is likely to occur if precautions are not seriously addressed. We present a 15-year-old girl who was diagnosed a left empyema thoracis. An attempt to place a chest drain in this young girl was almost fatal. A left ventricular repair together with thoracotomy and decortication were successful. This case emphasizes the rarity of this lethal complication and the importance of the correct technique for chest tube insertion.

Renal outcome following on- and off-pump coronary artery bypass graft surgery.

A prospective study was carried out to compare the outcomes of patients with preexisting non-dialysis-dependent renal dysfunction who underwent coronary artery bypass grafting with or without cardiopulmonary bypass. Elective off-pump coronary artery bypass was performed in 29 patients with renal dysfunction. Their results were compared with those of a similar group of 35 patients who underwent the conventional on-pump coronary artery grafting. There was a significant deterioration in creatinine clearance in the on-pump group on days 1, 2, and 4 after surgery, while creatinine clearance in the off-pump group remained close to the baseline level. Both groups had improved to the preoperative creatinine clearance values on follow-up at 4 weeks. It was concluded that off-pump surgery provided better renal protection than the conventional on-pump technique in patients with preexisting non-dialysis-dependent renal dysfunction.

Pedunculated Parietal Pleural Lesion: A Rare Presentation of Bronchogenic Cyst

We present a 35-year-old man with a preoperative diagnosis of a right lower lobe cystic mass. Misled by a radiological suggestion of an intraparenchymal lesion, he had a thoracotomy and right lower lobectomy. An intraoperative finding of a pedunculated cyst arising from the parietal pleural with subsequent histopathology confirmation of a benign bronchogenic cyst, however, would have made a less invasive surgical excision more appropriate.

Tricuspid valve papillary fibroelastoma: A rare tumor with a diagnostic dilemma

Papillary fibroelastoma is a rare primary tumor of the heart valves. This lesion can occur on any of the valves or endothelial surface of the heart and has been detected by echocardiography, by cardiac catheterization, during open heart operations for other conditions, and at autopsy. Because of the potential for comorbidities, this tumor should be removed. We present the case of an elderly man with a diagnosis of severe mitral valve regurgitation and moderate tricuspid valve regurgitation who was suspected to have a tricuspid valve vegetation. Mitral valve replacement, tricuspid valve repair, and excision of the lesion were performed successfully. A histologic examination of the vegetation confirmed it to be a papillary fibroelastoma. We present this case to emphasize the rarity of this tumor and the importance of a correct diagnosis to avoid delaying its prompt and definitive management.

Bismuth Paste Injection for Empyema Thoracis: A 100-Year-Old Method Revisited

Bismuth paste injection into the pleural cavity used to be a treatment for chronic empyema thoracis. This method, however, was long forgotten and scarcely practiced due to advanced surgical techniques and antibiotic therapy. We report a 50-year-old man with chronic empyema thoracis who was successfully treated with bismuth paste injection after a failed surgical decortication and a long-term chest drainage. This case highlights a trial of a 100-year-old method of bismuth paste injection which proved effective after standard measures had failed.

Selection of an appropriate left-sided double-lumen tube size for one-lung ventilation among Asians

Context: Selecting an appropriate size double-lumen tube (DLT) for one-lung ventilation has always been a challenge as most choose it based on experience or using the existing guidelines based on gender and height. Aims: The aim of this study was to determine if the appropriate choice of this tube could be based on the patients′ height, weight, tracheal diameter (TD), or the left main stem bronchus diameter (LMBD) and also to determine the relationship between height and depth of insertion among Asians. Subjects and Methods: This was a retrospective review of 179 patients who were intubated with a left-sided DLT and also had a posterior-anterior view of a digital chest radiograph for tracheal and left main bronchus diameter measurements. Additional data collected included patients′ demographics and DLT size used. Results: There were 123 (68.7%) males and 56 (31.3%) females with an overall mean age of 33.3 ± 16.3 years. Majority of the males (48.8%) used a size 39 Fr while females (46.4%) used a 35 Fr. There were weak correlations between DLT size with height (male: R2 = 0.222; female: R2 = 0.193), DLT size with weight (male: R2 = 0.109; female: R2 = 0.211), DLT size with TD (male: R2 = 0.027); female: R2 = 0.016), and DLT size with LMBD (male: R2 = 0.222; female: R2 = 0.193). There was a good correlation between depth of DLT inserted with patient′s height for both genders. Conclusion: The appropriate size of the left-sided DLT could not be predicted based on patients′ height, weight, tracheal or left main bronchus diameter alone in Asians; however, the depth of insertion of the tube was dependent on the height in both genders.

Chest Tube Entrapment: A Simple Solution for Technical Error

Unrecognized chest tube entrapment by surgical closure is a technical error. We present a rare case of chest tube entrapment that was successfully treated with a simple and safe solution in an elderly man after coronary artery bypass grafting (CABG). We visualized the suture using a small endoscope through the chest tube and incised it with the help of thoracoscopic scissors. The tube was then removed without the need for surgical exploration.

Delayed Ascending Aortic Dissection following Off-Pump Coronary Bypass Surgery in Preexisting Stanford B Dissection

Delayed ascending aortic dissection following coronary artery bypass surgery is a rare but lethal complication. We present the case of a 54-year-old man with a delayed acute Stanford A aortic dissection following an off-pump coronary artery bypass surgery in preexisting chronic type B disease. Such a case of an iatrogenic acute aortic dissection poses a significant challenge and dilemma in choosing the best technique for coronary revascularization in this group of patients. The pathophysiology and technical options are discussed.