Biphasic resection of a mandibular molar

Teeth once designated obsolete for rehabilitation and deemed for extraction should be re-evaluated for salvaging two thirds or even one-third component of the individual teeth. In our part of the continent, financial restraints can affect the orthodox procedures of root amputation if the final restoration is not provided at an earlier date. This case report enlightens on a biphasic approach combining radisection and coronal resection of a tooth with an endodontic perforation, which is a procedure not normally executed for mandibular molars but was adopted after taking the socioeconomic status of the patient into consideration

Nonsurgical endodontic management of cutaneously draining odontogenic sinus

Odontogenic cutaneous sinus tract is a rare but well documented condition. It is usually misdiagnosed as a local skin lesion and maltreated by systemic antibiotics and/ or surgical excision with eventual recurrence. This is because the primary etiology is incorrectly determined. We came across a 38 year old patient who presented with a cutaneous lesion on her left cheek with frequent purulent discharge and was not responding to systemic antibiotics. The case history, diagnosis and management of this condition is presented here

Surgical management of gastro-esophageal reflux and hiatus hernia in a thoracic surgery unit

Few data have been published that permit comparison of the various surgical procedures used today for hiatal hernia, gastro-esophageal reflux disease [GERD], or both. The present study was aimed to evaluate efficacy of different surgical procedures performed for elimination of hiatal hernia and relief of symptoms and complications of gastro-esophageal reflux. Between 1987 and 1996, 134 patients undergoing a primary surgery for hiatal hernia, GERD or both were evaluated. Appropriate procedure was selected on the basis of the anatomical and functional findings assessed by means of barium, endoscopy, manometry and prolonged pH monitoring. Nissen fundoplication [n=85], by abdominal approach was mainly reserved for sliding hiatus hernia associated with GERD with minimal or no mucosal inflammation and normal motility on esophageal manometry. Thoracic [n=29] approach was considered in patients with esophageal shortening. Belsey Mark-IV [n=20] was the preferred procedure in the presence of impaired motility and no evidence of severe esophageal inflammation or shortening. The symptoms at review were assessed and graded according to previously published criteria. Patients with recurrent symptoms were fully re-investigated. Mean follow-up was 4.95 years [range 0.5-16 years]. Overall excellent or good results were achieved in 123[91.79%] patients, 93.90% in trans-abdominal Nissen, 89.65% in transthoracic Nissen and 88.23% in BM-IV group, p = 0.02. These data suggest that where the appropriate procedure is selected, surgery can achieve satisfactory success rate

Rare intramural bronchogenic cyst of esophagus

Peri-esophageal bronchogenic cysts are well recognised and have been frequently reported in literature. On the contrary, complete intramural bronchogenic cyst of esophagus is a very rare entity. We report a 29 years old female patient, who was managed on 'wait and observe policy', for presumed benign intramural cyst of the esophagus for over 7 years. This resulted in dense pericystic adhesions and overlying muscular atrophy which caused difficulties during operation. Waiting for symptoms before resection leads to increased operative risk, therefore, early surgery, regardless of age, symptoms or location is strongly recommended

Thoracoscopic or open pleurectomy for spontaneous pneumothorax? A common question about a common problem

To analyse and compare the efficiency of video-assisted thoracoscopic surgery [VATS] and open pleurectomy for spontaneous pneumothorax. Design: Retrospective cohort of patients who underwent VATS/open pleurectomy for spontaneous pneumothorax. Place and Duration of Study: This study was carried out at Walsgrave Hospital Coventry, U.K over a period of 5 years. Subjects and Fifty-seven patients, 36 males and 21 females were studied. Thirty-one patients underwent open pleurectomy with median age of 36.45 years. VATS pleurectomy was carried out on 26 patients with median age of 40.03 years. The operative time, amount of analgesia used on the first five days, the duration and drainage of chest, hospital stay and recurrence rate were compared. Data was analyzed using STATISTICA [Statsoft, Tulsa,OK] in Windows programme. The median operating time was significantly longer in open group [72.4 vs 55 minutes; p = 0.005]. The amount of analgesia required in first 5 days was significantly more in open group [108.03 vs 46.92 mg; p = 0.02]. Chest drainage was significantly more in open group [1027.14 vs 652.80 ml; p = 0.04]. However, chest drain duration and hospital stay had no significant difference. VATS emerged as cost-effective modality [pound 1770.78 vs pound 3226.05]. However, there were 3[5.27%] recurrences in VATS group. We conclude from our experience that VATS pleurectomy is an appropriate modality to treat uncomplicated especially primary spontaneous pneumothorax. However, open pleurectomy is a viable alternative in complicated especially secondary spontaneous pneumothorax

Gangrene of the lung: Asurgical challenge

A 58 years old Caucasian gentleman was transferred to Regional Thoracic Surgical Unit from another institution with cough, sputum, fever, chills and right sided pleuritic pain. About 13 months ago, he had total laryngectomy, permanent tracheostomy and left sided radical block neck dissection for supraglottic squamous cell carcinoma with subsequent radical radiotherapy [64 gy 32 fraction 6 and half week]. On arrival, he was dehydrated and cachetic with poor dental hygiene. His blood pressure was 82/60 mmHg, pulse rate 160/min and respiration 40/min. Temperature was 39.4 degree centigrade. Clinical assessment revealed decreased air entry, dull percussion note and patch of bronchial breathing in right upper zone. Initial laboratory investigations revealed a WBC count of 12,800/mm3, an arterial pH of 7.38, a Pao2 of 72 mmHg, a Paco2 of 15 mmHg and a bicarbonate concentration of 9 mmol/l. Sputum gram staining revealed heavy concentration of gram-positive cocci, gram negative diplococci, and gram-negative bacilli. Sputum stained using Ziehl-Neelsen's method did not show any acid-fast organisms. The chest radiograph and CT scans were suggestive of right upper lobe consolidation with air bronchogram mainly occupied by multiple cavities and sloughed lung parenchyma. The initial treatment consisted of intravenous fluids, oxygen, clindamycin, 600 mg I/V given 8 hourly, and cefotaxime 2g I/V, 8h. Forty-eight hours after admission, the patient was still quite ill. Klebsiella pneumoniae was isolated from both sputum and blood. Anaerobic blood cultures were negative. The antibiotics were changed to gentamycin, 140 mg I/V, 8h, and cefuroxime, 1.5 g I/V, 8h. Seventy-two hours after admission, the radiographic picture was unchanged and the patient appeared to be in septic condition with white blood cell count of 24,000 mm3. At this stage, bronchoscopic examination revealed only frothy, white, non-purulent material issuing from the right upper lobe orifice; the examination was otherwise normal. Right sided video assisted thoracoscopy [VATS] was carried out as a diagnostic as well as therapeutic measure. It surprisingly revealed, necrotic right lung accompanied with empyema. About 600 ml of pus was evacuated. Empyema cavity was debrided and chest tubes were placed under vision. Culture of the pleural fluid was positive for Klebsiella pneumoniae but negative for anaerobes. Serial pleural washouts were carried out every 24 hours with normal saline and the pleural fluid was sent for culture every alternative day. Within 7 days, the pleural cavity became clean and his clinical status improved. Right explorative thoracotomy was undertaken which proceeded to right upper and middle bilobectomies. Pathology results were consistent with lung necrosis associated with superimposed polymicrobial infection. There was preservation of alveolar architecture with evidence of thrombotic occlusion of the terminal pulmonary vasculature. The patient had an uneventful recovery and discharged on the tenth postoperative day

Surgical Management of gastro-esophageal reflux and hiatus hernia in a thoracic surgery unit

Few data have been published that permit comparison of the various surgical procedures used today for hiatal hernia, gastro-esophageal reflux disease [GERD], or both. The present study was aimed to evaluate efficacy of different surgical procedures performed for elimination of hiatal hernia and relief of symptoms and complications of gastro-esophageal reflux. Between 1987 and 1996, 134 patients undergoing a primary surgery for hiatal hernia, GERD or both were evaluated. Appropriate procedure was selected on the basis of the anatomical and functional findings assessed by means of barium, endoscopy, manometry and prolonged pH monitoring. Nissen fundoplication [n=85], by abdominal approach was mainly reserved for sliding hiatus hernia associated with GERD with minimal or no mucosal inflammation and normal motility on esophageal manometry. Thoracic [n=29] approach was considered in patients with esophageal shortening. Belsey Mark-IV [n=20] was the preferred procedure in the presence of impaired motility and no evidence of severe esophageal inflammation or shortening. The symptoms at review were assessed and graded according to previously published criteria. Patients with recurrent symptoms were fully re-investigated. Mean follow-up was 4.95 years [range 0.5-16 years]. Overall excellent or good results were achieved in 123[91.79%] patients, 93.90% in trans-abdominal Nissen, 89.65% in transthoracic Nissen and 88.23% in BM-IV group, p = 0.02. These data suggest that where the appropriate procedure is selected, surgery can achieve satisfactory success rate

Pulmonary metastases, surgery and prognostic indicators: Review of 8 - year experience

Value of surgery and prognostic indicators for pulmonary metastases were studied to establish appropriate criteria for patient selection influencing long-term survival at Hairmyres Hospital, East Kilbride Glasgow, U.K. Between 1988 and 1996, 28 patients were treated for pulmonary metastases mainly with metastasectomy, 21 patients had resections with curative intent. Unfortunately, 7 patients were unsuitable for surgery. At subsequent relapse, 2 patients had second stage surgery, while 15 patients had adjuvant thera pies [chemotherapy / radiotherapy / combination]. The origin of primary tumor was epithelial in 17 [60.71%; cases, sarcoma in 4[14.29%], germ cell carcinoma in 3[10.71%] melanoma in 1[3.57%], and 3[10.71%] were of unknown histology. Actuarial surival amongst the patients who had resection with curative intent and for incomplete resection, inoperable or unfit patients were 61.9% and 21.5% at Ist year, 23.8% and 8% at 5 year, 14.2% and 3% at 10 years. Overall median survival was 36 months after a mean follow-up of 48 months with the range being 1-98 months and 14 month for lateral group. 4[19%] patients of same group died during follow up with mean survival of 30.7 months. Among formal group, the 5 year survival was 17.8% with disease free interval of > 6 months, and in 3.5% < 6 months respectively. Median survival of 37 months for solitary unilateral lesions, 25 months for multiple / bilateral lesions, 108 months for germ cell tumor, 24 months for other histologies, 36 months with adjuvant therapy and 25 months without such measures. Univariate analysis confirmed that metastasectomy is a safe, potentially curative procedure for better prognosis of solitary metastases disease-free interval [DFI] of > 6 months, germ cell tumor and adjuvant therapy in selected cases