Sameh Ibrahim Sersar

Inhaled Foreign Bodies: Presentation, Management and Value of History and Plain Chest Radiography in Delayed Presentation

OBJECTIVES: To assess the clinical and management aspects of tracheobronchial foreign body (FB) in children and adults; to judge the influence of the operators experience on the outcome of the procedure and to evaluate the factors associated with delayed diagnosis of FB aspiration (FBA) in children; and to compare clinical, radiologic and bronchoscopic findings in the patients with suspected FB inhalation (FBI). STUDY DESIGN AND SETTING: Retrospective review of a 10-year experience (from 1995 to 2005), involving a 1512-bed Mansoura university hospital and a 184-bed Mansoura emergency hospital. MATERIAL AND METHODS: Three thousand three hundred patients underwent rigid bronchoscopy for suspected FBI between 1995 and 2005 in Mansoura, Egypt. The data were analyzed in 3 groups: the patients with negative bronchoscopy for FBI (group 1), early (group 2), and delayed diagnosis (group 3). Foreign body was removed using the rigid bronchoscope with or without using the extracting forceps (Egyptian novel technique; Sersar technique). RESULTS: The penetration syndrome and decreased breath sounds were determined in a significantly higher number of the patients with FBI. The plain chest radiography revealed radiopaque foreign bodies (FBs) in 23.56% of all patients with FBI. Pneumonia and atelectasis were more common in the groups with negative bronchoscopy and with delayed diagnosis (P < 0.01). The FBs were mostly of vegetable origin, such as seeds and peanuts. The Egyptian novel (Sersar) technique was used since 2004 April in 100 cases (4.62%) with a history of FBI (pins and or small rounded materials). It was successful in 73 cases of nonimpacted inhaled pins. CONCLUSIONS: Bronchoscopy is indicated on appropriate history and on suspicion. To prevent delayed diagnosis, characteristic symptoms, and clinical and radiologic signs of FBI should be checked in all suspected cases. Because clinical and radiologic findings of FBI in delayed cases may mimic other disorders, the clinician must be aware of the likelihood of FBI. EBM rating: C-4

Left Ventricular Rupture Post Mitral Valve Replacement

Prevention is better than cure best applies here. As per many authors, posterior leaflet chordae preservation prevent Left ventricular rupture (LVR) and preserve LV geometry. We are presenting here 5 types of left ventricular rupture (LVR) post Mitral valve replacement (MVR) with different methods to repair with the advantages and disadvantages of each. The mortality rate is still very high despite the advances in cardiac surgery. Many therapeutic approaches have been adopted. Yet, none is ideal.

Emergency thoracotomies: Two center study

Introduction and Aim: Emergency thoracotomy is performed either immediately at the scene of injury, in the emergency department or in the operating room. It aims to evacuate the pericardial tamponade, control the haemorrhage, to ease the open cardiac massage and to cross-clamp the descending thoracic aorta to redistribute blood flow and maybe to limit sub-diaphragmatic haemorrhage, bleeding and iatrogenic injury are the common risk factors. We aimed to review our experience in the field of emergency thoracotomies, identify the predictors of death, analyze the early results, detect the risk factors and asses the mortalities and their risk factors. Patients and Methods: Our hospital records of 197 patients who underwent emergency thoracotomy were reviewed. We retrospectively analyzed a piece of the extensive experience of the Mansoura University Hospitals and Mansoura Emergency Hospital; Egypt and Saudi German Hospitals; Jeddah in the last 12 years in the management of trauma cases for whom emergency thoracotomy. The aim was to analyse the early results of such cases and to detect the risk factors of dismal prognosis. Results: Our series included 197 cases of emergency thoractomies in Mansoura; Egypt and SGH; Jeddah; KSA in the last 12 years. The mean age of the victims was 28 years and ranged between 5 and 62 years. Of the 197 patients with emergency thoracotomy, the indications were both penetrating and blunt chest trauma, iatrogenic and postoperative hemodynamito a surgical cause. The commonest indication was stab heart followed by traumatic diaphragmatic ruptures. Conclusion: The results of emergency thoracotomy in our series were cooping with the results of other reports, mainly due to our aggressive measures to achieve rapid stabilization of the hemodynamic condition. We emphasize the importance of emergency medicine education programs on rapid diagnosis of traumatic injuries with early intervention, and adequate hemodynamic and respiratory support. Emergency thoracotomy has an important role in emergency big volume hospitals and can save a lot of lives. Outcome can be improved by increasing the learning curve and the integrated cooperation of the emergency and surgical teams.

Octreotide for Management of Chylothorax following Bidirectional Glenn in a Three-Month-Old Infant. Comment

Abstract  Background: Chylothorax developing after open heart surgery for congenital heart defects can be a challenging problem. Established therapies are not always efficacious. This report summarizes our experience using octreotide as an adjunct in the management of an intractable chylous effusion. Methods: The patient described underwent a bilateral bidirectional cavopulmonary anastomosis at 3 months of age. Postoperatively, the patient demonstrated significant quantities of milky fluid drainage from the right pleural chest tube. Initial management included diuretics, afterload reduction, and a non‐fat diet. These maneuvers appeared to be effective. However, the patient experienced a recurrence of the effusion requiring re‐admission to the hospital and re‐insertion of a right pleural chest tube. Given the recalcitrant nature of the effusion, an infusion of octreotide was begun. Results: An octreotide infusion was begun at 1 mcg/kg/hr and gradually increased to 3 mcg/kg/hr. Chest tube drainage diminished allowing chest tube removal 13 days later. The octreotide infusion was weaned off over the subsequent 10 days without any further effusion problems. Conclusions: Octreotide may be a useful adjunct in the management of intractable chylous effusions following congenital heart surgery.

A self-introduced sharp metallic foreign body migrating transcutaneously to the interventricular septum, mistaken as an inhaled pin.

only modest. After surgical annuloplasty to reduce annular size, significant mitral stenosis develops beyond annular size reduction by limited leaflet opening with diastolic tethering. Dr Frater’s previous investigations, demonstrating the presence of leaflet tethering in diastole, provide conceptual support and explanation for the development of functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation. These concepts have clear therapeutic implications regarding the need to address subvalvular tethering for repair of both systolic and diastolic dysfunction of the mitral apparatus. The observation in Dr Frater’s letter regarding the heterogeneous influences on diastolic leaflet mobility from papillarymuscle displacement is of special interest. He observed that papillary muscle separation with its lateral and posterior displacement causes greater impairment on diastolic mitral leaflet opening than does papillarymuscle apical displacement.Althoughwehavenot performed 3-dimensional analysis of papillary muscle position, we agree with his observation, because papillary muscle tip position by echocardiography seems to be displaced laterally and posteriorly but not apically in many patients.We referred to ‘‘outward displacement’’ as ‘‘lateral and posterior displacement’’ in our publications. We expect that ‘‘outward’’ or ‘‘lateral and posterior’’ displacement of papillary muscle will cause tensed and posteriorly displaced chordae to limit anterior leaflet opening, leading to functional mitral stenosis in diastole, whereas apical displacement may not displace chordae posteriorly and resultant effects to restrict leaflet opening may be only modest. The direction and degree of papillary muscle displacement are key factors to address subvalvular tethering and provide comprehensive surgical relief for ischemic mitral regurgitation and/or stenosis. We look forward to Dr Frater’s publication of his

Contegra and extracardiac Fontan

References 1. Guerrieri Wolf L, Choudhary BP, Abu-Omar Y, Taggart DP. Solid and gaseous cerebral microembolization after biological and mechanical aortic valve replacement: investigation with multirange and multifrequency transcranial Doppler ultrasound. J Thorac Cardiovasc Surg. 2008;135:512-20. 2. Markus HS, Punter M. Can transcranial Doppler discriminate between solid and gaseous microemboli? Assessment of a dual-frequency transducer system. Stroke. 2005;36:1731-4.

Therapeutic approaches for inhalation of veil pins: local Egyptian experience.

A new type of foreign body inhalation that is the veil and head scarf pin has recently become more common. Accidental inhalation of these pins can occur while holding them between the lips when putting on the veils or head scarfs. Veil pins are radio opaque and are therefore easily diagnosed by plain chest x-ray and or fluoroscopy (1). Foreign body aspiration in general is a well-known phenomenon, which is generally common during infancy. The nature of the inhaled foreign bodies in general is influenced by crop diversity, harvest season and sociocultural factors (2). This short communication is a retrospective analysis of 144 cases of inhaled veil pins between 1999 and 2006 in three centres, which are Mansoura University Hospital, The Emergency Hospital and a private hospital in Mansoura. The demographic, clinical, x-ray and therapeutic data were analysed, including the age and gender of the patients, symptoms and signs, and radiological and the rigid bronchoscopic findings. The diagnosis was made on the basis of chest x-ray and or rigid bronchoscopy. The inhaled veil pins were removed either with or without the use of extracting forceps. Attempts were made to remove the pins by rigid bronchoscopy under general anaesthesia. Three methods can then be used for removal. One end of the veil pin is grasped and pulled into the bronchoscope out under vision; (technique 1). An important point is that we teach the junior staff to make sure that they see the pin very well and that they are holding it without surrounding mucosa. Alternatively, the middle of the pin is pulled against the inner opening of the bronchoscope until it bends into a U-shape and then the middle of the bent pin is pulled out thus protecting the airway and lessening the chance of airway injury (technique 2). We introduced a third method to remove a foreign body from the airway using the rigid bronchoscope without forceps, but using postural drainage (technique 3). It is mainly a reuse and revival of the concept of postural drainage of the airways. The patients’ demographic, radiological and bronchoscopic data are shown in Table 1. The complications encountered during rigid bronchoscopy and the results of different attempts to remove the pins are given in Table 2. The success of different techniques is shown in Table 3. The mean age was 14 years. Most of the patients had a history of aspiration, choking and coughing. The most common presentation in our series was history of pin inhalation followed by sudden cough after choking. There were no specific clinical signs on examination, as this is a non-obstructing foreign body aspiration mostly of acute presentation requiring rapid intervention. Postero-anterior and ⁄ or lateral chest x-rays demonstrated the presence of foreign bodies in all cases (radio-opaque veil or scarf pins). These patients almost always presented early (within 1 week). After bronchoscopy, laryngeal oedema was recorded in 10 cases. Reversible cardiac arrest which was successfully resuscitated was reported in three cases. Major airway injury with massive bleeding and death was reported in one case and barotrauma requiring an inter-costal chest tube in three cases. First bronchoscopy was successful in 114 patients (79%). In three of the 30 unsuccessful cases, the foreign body was spontaneously rejected by coughing; therefore, a second attempt for removal by bronchoscopy was made in only 27 patients (18.8%); 13 of these attempts were successful. In the remaining 14 patients (9.7%), six pins were removed by a third attempt with bronchoscopy. Eight patients (5.6%) needed bronchotomy; no patient required pulmonary resection. Techniques 1, 2 and 3 were Acta Pædiatrica ISSN 0803–5253

Impacted thoracic foreign bodies after penetrating chest trauma

Background Retained foreign bodies in the chest may include shell fragments, bullets, shrapnel, pieces of clothing, bones, and rib fragments. The risks of removal of foreign bodies must be weighed against the complications of leaving them inside the chest. Methods We treated 90 cases of retained intrathoracic foreign bodies in patients admitted to 3 tertiary centers in Saudi Arabia between March 2015 and March 2016. Sixty patients were injured by shrapnel, 26 had one or more bullets, 3 had broken rib fragments, and one had a metal screw. The chest wall was site of impaction in 48 cases, the lungs in 24, pleura in 14, and mediastinum in 4. Results Removal of the retained foreign body was carried out in 12 patients only: bullets in 9 cases, bone fragments in 2, and a metal screw in one. The predictors for removal were bullets, female sex, and mediastinal position with bilateral chest injury, especially with fracture ribs. Conclusion Retained intrathoracic foreign bodies due to penetrating chest trauma are treated mainly conservatively unless there is another indication for chest exploration.

Post-traumatic ruptured gastrothorax mimicking chylothorax.

The presence of the stomach in the chest is called gastrothorax. Few cases were reported. Most of them were related to congenital diaphragmatic hernia.

Is Interrupted Inferior Vena Cava a Risk Factor in Cases of Bilateral Bidirectional Glenn

INTRODUCTION Bilateral superior vena cava-to-pulmonary artery anastomoses are technically challenging. Bilateral superior vena cavae (SVCs) have been thought to be a risk factor for poor outcome in children needing single-ventricle palliation. METHODS The files of forty children who underwent bilateral cavopulmonary anastomoses (CPAs) were reviewed. RESULTS Forty patients (31 male, 9 female) had bilateral bidirectional Glenn shunts in King Faisal Specialist Hospital and Research Center, Jeddah, in 7 years. Interrupted inferior vena cava (IIVC) was present in 8 patients. All IIVC cases featured a hypoplastic right ventricle. Twenty-four patients had a hypoplastic right ventricular morphology, and 16 patients had a hypoplastic left ventricular morphology. CONCLUSIONS In single-ventricle anatomy, cases of a bilateral SVC are more often associated with an IIVC than a single SVC. Patients who undergo bilateral CPAs with an IIVC have a difficult early postoperative course. We should look for IIVC and either exclude or prove IIVC in cases of bilateral SVCs. Postoperative anticoagulation therapy in children with bilateral CPAs is important but should be investigated further.