Roy Thankachen

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.

Right ventricular hydatid cyst excision without the use of cardiopulmonary bypass

A 22-year-old gentleman, from the North of India, presented with a history of dyspnea and angina on exertion for the last 6 months. His transthoracic echocardiography demonstrated a heterogeneous mass with multiple hypoechoic spaces occupying the right ventricular anterior wall extending onto the ventricular outflow tract (Fig. 1a). A computed tomography of the thorax showed a multiloculated mass in the myocardium of the right ventricle with compression of the right ventricular outflow tract (Fig. 1b). A decision to excise the cyst without the use of cardiopulmonary bypass was taken, keeping in mind the anatomical site of the cyst. The cyst was localized to the anterior right ventricular wall extending onto the outflow tract (Fig. 2a). Precautionary measures in the event of a right ventricular entry were kept in place, including aortic, main pulmonary artery and caval tapes and cardiopulmonary bypass standby. A longitudinal incision was placed over the right ventricle extending onto the ventricular outflow area. The overlying myocardium was dissected off the glistening outer cuticular layer or ectocyst, derived from the host. The cyst was decompressed and sterilized by injecting 5 % cetrimide solution into the cystic cavity, after aspirating some of the hydatid fluid. The cyst was incised, and the germinal membranes were emptied from the cavity which also contained multiple daughter cysts (Fig. 2b). The pericystic tissue was resected as widely as possible, and the cavity was left open. The base of the cyst wall opening into the right ventricular outflow tract was repaired with pledgetted polypropylene sutures (Fig. 2c). Postoperative period remained uneventful. Resection under cardiopulmonary bypass has been considered the safest method, with the least risk of spillage of cyst contents during the procedure [1]. Excision of the cysts without the use of cardiopulmonary bypass offers a safe option in the case of intramyocardial cysts sited on the right ventricle and its outflow provided all surgical complications and their management are prepared for. Surgical complications of entering the right ventricle and embolization of the cysts into the pulmonary artery were kept in mind. Plans to reconstruct the right ventricle on a beating heart with a pericardial patch were made. The need for cross-clamping the main pulmonary artery in the event of spillage of cyst contents into the RV was considered. This would necessitate establishing extra corporeal circulation. Recurrences should be routinely screened for in hydatid disease of the heart. Present radiology and echocardiographic methods still do not reveal small cysts. The possibilities of recurrence due to accidental spillage or a small cyst not seen at the time of surgery always exist. Pharmacotherapy postoperatively would decrease the * Ravi Shankar ravixshanker@cmcvellore.ac.in

An unusual tumor of rib diaphysis—report of a giant cell tumor and a brief review of literature

Giant Cell Tumor of bone (GCT) is a benign but aggressive tumor, which forms about 4–5% of primary bone tumors and 1–2% of all chest wall tumors. It arises in the epiphysis of bones. The epiphysis of a rib is in its head and tubercle posteriorly and hence a GCT arising in a rib’s anterior aspect, its diaphysis, is rare. In this unusual position, it can be mistaken for other more common diaphyseal pathologies. Radiological images are often diagnostic. A needle biopsy is best avoided and a wide excision biopsy is the treatment of choice. Microscopically, multinucleated giant cells are seen amidst stromal cells. Giant cells like these are also seen in other diseases like the brown tumor of primary hyperparathyroidism. Giant cell lesions are never caused by secondary hyperparathyroidism. We present a case of a diaphyseal GCT of rib in a patient with secondary hyperparathyroidism who was successfully treated.