Roy John Korula

Mechanisms of cardiac perforation leading to tamponade in balloon mitral valvuloplasty

Mechanisms of cardiac perforation in 10 cases of cardiac tamponade encountered in a single-center series of 903 balloon mitral valvuloplasty procedures were elucidated by precise localization of the site of perforation at subsequent surgery. These mechanisms were perforation of the aortic root and adjacent right atrium by sliding up of the transseptal set (2), apical tears by straight-tip balloon catheters driven distally during mitral valve dilatation (3), apical perforations by guidewires introduced through catheters wedged in the apex (2), tear of the posterior right atrial wall by dilatation of the track produced by very low septal punctures (2), and right ventricular perforation by a pacing catheter (1). Multivariate analysis showed cardiac perforation to be significantly related to the total experience at the center (inversely) and to patient age (directly). Left ventricular perforation occurred exclusively in patients > 40 yr of age. Understanding these mechanisms has enabled formulation of effective strategies to prevent cardiac perforation.

TRANSPLANT KIDNEY PROTECTION DURING AORTIC ANEURYSM SURGERY

PURPOSE Renal allografts are sensitive to ischemic insult. During aortic cross clamping prevention of ischemic damage to a kidney below an aneurysm is vital. Many maneuvers have been reported. We describe a simple technique of protecting the transplant kidney from ischemic damage during aortic surgery. MATERIALS AND METHODS During vascular cross clamping a sterile ice slush was placed around the kidney for surface cooling, obviating the need for some of the complicated procedures previously reported. RESULTS After removal of the ice slush and clamps, urine production resumed and creatinine levels remained unchanged. CONCLUSIONS External cooling with ice slush provides adequate renal protection during aortic cross clamping and requires no special expertise or equipment.

Surgical results in bronchiectasis: analysis of 149 patients.

Bronchiectasis remains a serious problem in developing countries. We reviewed the morbidity, mortality, and functional outcome of surgical treatment for bronchiectasis in our institution. Between 1992 and 2003, 149 patients (105 males, 44 females) underwent pulmonary resection for bronchiectasis. Their mean age was 33.7 years (range, 5–66 years). The indications for surgery were failure of conservative treatment in 59 (40%) patients, recurrent hemoptysis in 53 (36%), bronchial obstruction by a tumor in 9 (6%), and destroyed lung in 28 (19%). Bilateral disease was seen in 24 (16%) patients. Surgical treatment included pneumonectomy in 55 (37%) patients, lobectomy in 55 (37%), bilobectomy in 37 (25%), and lobectomy and/or segmentectomy in 2 (1%). There was one operative death (mortality, 0.67%) and morbidity occurred in 22 (14.8%) patients. Follow-up was complete in 94 patients, for a mean of 4.8 years (range, 3 months to 12 years). After surgery, 51 (34%) patients were asymptomatic. Surgical treatment for bronchiectasis can achieve good results with acceptable morbidity and mortality, not only in localized disease but also in extensive disease, if complete resection can be achieved.

Aortic and Mitral Valve Replacement in a Patient with Hemophilia B

A 25-year-old man with factor IX deficiency had an aortic and mitral valve replacement using a 2M Starr Edwards valve in the mitral position and a 22 Medtronic valve in the aortic position under cover of factor IX concentrate. The surgical procedure and the immediate postoperative period were uneventful except for a pericardial effusion which required a pericardiostomy. He was anticoagulated with heparin in the immediate postoperative period while the factor IX concentrate was being administered. Oral anticoagulation with acenocoumarol (Acitrom®) was started, maintaining the international normalized ratio between 1.5 and 2. He was doing well at follow-up 9 months later.

Omental pedicle flap for the management of postoperative bronchopleural fistulae

Nine patients, who had previously undergone pneumonectomy (3) or lobctomy (6), were treated for bronchopleural fistulae using a pedicled omental flap. After adequate evacuation of the pleural space and control of infection, the omentum was harvested with an intact gastroepiploic arch and through an upper midline laparotomy and then transferred to the affected hemithorax. Successful closure was achieved in all the cases. The empyema spaces got completely obliterated without any recurrences, leaving no cosmetic defect.

Primary bronchial leiomyosarcoma

Leiomyosarcoma is a malignant neoplasm of smooth muscle and occurs very rarely as a primary tumour in the lung. A case with a rapidly progressive clinical course is berein reported and the diagnostic and therapeutic possibilities discussed.

Mucous cell adenoma originating from bronchial gland

The clinical and pathological features of a mucous adenoma arising from bronchial gland and manifesting with productive cough and dyspnoea over a period of four years in a 44-year-old male is presented. Origin of the tumour from the proximal part of the bronchial tree necessitated a pneumonectomy with resultant cure.

Oesophageal stenosis due to tracheo bronchial remnants

Dysphagia due to an intrinsic congenital malformation causing oesophageal stenosis is rarely seen in adults. Histopathology of the obstructive lesion revealed tracheo bronchial remnants. This unusual cause of dysphagia and its surgical treatment is discussed.

Benign oesophagobronchial fistulae

Two patients with recurrent long-standing pulmonary infection underwent surgery for bronchiectasis. At operation an oesophageal communication was observed. The oesophageal fistula was divided and lobectomy performed. Both have done well following surgery. Diagnosis and management of oesophagobronchial fistula is discussed along with a review of relevant literature.