ABSTRACT
A 13-year-old boy underwent tracheostomy due to post-cardiac arrest encephalopathy in our hospital. During the second postoperative month, massive bleeding from the tracheostomy tube lumen was observed; tracheoinnominate artery fistula was diagnosed. Two weeks postoperatively, the trachea collapsed; tracheoplasty with VA-ECMO was performed. The patient was placed in respiratory distress and the tracheostomy cannula was removed. The damaged part of the trachea was trimmed to form a fusiform structure, while the horizontal mattress suture technique was used for tracheoplasty. An endotracheal tube was then placed just above the tracheal bifurcation and the tracheoplasty site was rested. On postoperative day 15, the tube was changed to a tracheostomy one; 3 months postoperatively, no tracheostomy-related complications or rebleeding were observed. Therefore, VA-ECMO assisted tracheal repair is considered a useful treatment option for patients with tracheal disruption, where suturing a prosthesis to the tracheostomy stoma site is difficult.
ABSTRACT
A 68-year-old man visited a family physician with a complaint of epigastric pain lasting several hours. Computed tomography revealed an abdominal aortic aneurysm that was 60 mm in length and a small amount of ascites, resulting in a tentative diagnosis of impending rupture of the abdominal aortic aneurysm. The patient was referred to our hospital and underwent emergency surgery. Intraoperative findings ruled out rupture and inflammatory changes in the abdominal aortic aneurysm. We observed the abdominal cavity and detected an internal hernia. The 15-cm-long ileum was incarcerated by an abnormal cord between the vesicorectal fossa and peritoneum. The cord was dissected to release the internal hernia. Intestinal peristalsis and pulsation of the marginal artery were maintained, allowing us to avoid intestinal resection. The patient reported that his epigastric pain disappeared soon after surgery. On the 24th postoperative day, the patient underwent abdominal aortic replacement. Our case suggests that internal hernia incarceration is an important differential diagnosis of impending rupture of an abdominal aortic aneurysm, even in cases with no history of laparotomy.
ABSTRACT
The patient was a six-month-old girl with an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). She had fever and visited a family physician at 5 months of age. Because of poor oxygenation, she was referred to our pediatric department and intubated soon after hospitalization. Echocardiography showed that the orifice of left coronary artery was just above pulmonary commissure, the left ventricular ejection fraction was 9%, and the level of mitral regurgitation was moderate. Right coronary angiography showed that the left coronary artery contrasted against the collateral arteries. The left coronary artery originated from the left side of the pulmonary trunk. After recovery of the general condition with medical therapy, the patient underwent coronary artery reconstruction by the modified spiral cuff technique on the 21st day of hospitalization. The temporary detachment of pulmonary valve and its commissure for making a margin around the left coronary artery enabled us to make the spiral cuff in almost the usual manner. She was moved to the intensive care unit with the support of extracorporeal membrane oxygenation (VA-ECMO) and was successfully weaned off the VA-ECMO 5 days after the surgery. The postoperative course was good, and she was discharged from our hospital 3 months after the surgery. The echocardiogram one year after the surgery showed a left ventricular ejection fraction of 30%, mild mitral regurgitation, and mild pulmonary regurgitation. Our experience indicates that the spiral cuff technique is a useful coronary reconstruction method for the treatment of ALCAPA, especially in cases presenting a considerable distance between the origin of the left coronary artery and the transplantation site. There are few reports regarding the surgical treatment of infantile ALCAPA showing reduced left ventricular function. Coronary artery reconstruction using the spiral cuff method and planned VA-ECMO are useful surgical procedures in such cases. Our experience also suggests that the establishment of a treatment strategy including mechanical support is essential to improve the results in severe ALCAPA cases.
ABSTRACT
A 17-days-old-girl with pulmonary artery (PA) sling, patent ductus arteriosus (PDA), and persistent left superior vena cava was admitted to our hospital. Despite good respiratory status just after birth, the respiratory status gradually worsened, and tracheal intubation was performed on 13th day after birth. Emergency division of the PDA was conducted on day 16. Although preoperative computed-tomography did not demonstrate tracheal stenosis, bronchoscopy after tracheal intubation revealed progression of tracheal stenosis with difficulty for stable anesthetic management. Therefore, operation was postponed to re-evaluate tracheal stenosis. Bronchoscopy and computed-tomography revealed the worsening of tracheal stenosis. Eventually, we performed total correction of the PA sling and tracheal stenosis on day 17. Cardiopulmonary bypass was established after median sternotomy. After transection of the PDA, the left PA originating from the right PA was also transected, and transplanted to the main PA. Then, sliding tracheoplasty was performed following the division of the tracheal stenotic region. Her respiratory condition improved after operation, and postoperative computed-tomography showed successful correction of tracheal stenosis. Although few such cases were reported for neonatal PA sling requiring concomitant tracheoplasty, this case suggests that total correction of PA sling and tracheal stenosis is feasible and useful surgical procedure for such cases.