Simplified access for division of the low cervical/high thoracic H-type tracheoesophageal fistula.

H-type tracheoesophageal fistulas (H-TEF) often are located in the low cervical/high thoracic region where determination of the most appropriate surgical approach is difficult. When it can provide adequate exposure, a cervical incision is preferred because of the likelihood of decreased morbidity. A child with VACTERL association presented with recurrent respiratory problems. Esophagogram showed an H-TEF below the level of the clavicle. A vascular guide wire was placed through the H-TEF with the ends brought out through the mouth. Under fluoroscopic guidance, gentle traction was placed on the wire to bring the fistula into the neck for an easily accessible cervical exposure, thus eliminating the need for a thoracotomy.

Endoscopic thoracic sympathectomy.

OBJECT: Thoracic sympathectomy has evolved as a treatment option for patients with hyperhidrosis and pain disorders. In the past, surgical procedures were highly invasive and caused significant morbidity, but the minimally invasive thoracoscopic procedure provides detailed visualization of the sympathetic ganglia and is associated with minimal postoperative morbidity. METHODS: The authors performed 112 thoracoscopic sympathectomy procedures in 65 patients, and the outcomes were equivalent to those previously established for open surgical techniques; however, the rate of surgery-related morbidity, length of hospital stay, and time until return to normal activity were substantially reduced. Complications and recurrence of symptoms were comparable with those demonstrated in previous reports. Overall patient satisfaction and willingness to undergo a repeated operative procedure ranged from 66 to 99%. Postoperatively, higher satisfaction rates were observed in patients with hyperhidrosis whereas in those with pain syndromes, satisfaction rates were lower. CONCLUSIONS: Minimally invasive thoracoscopic sympathectomy procedures are useful in treating sympathetically mediated disorders, and the results indicate that the procedure is associated with reduced morbidity and similar outcome when compared with results obtained after open surgery. Hyperhidrosis is well treated, but patients with pain syndromes have significantly poorer outcomes.

Pulmonary sequestration presenting as mitral valve insufficiency.

Although pulmonary sequestrations commonly present with infectious complications, problems relating to high blood flow through the lesion are rarely apparent. A 4-year-old girl was referred for cardiac catheterization and evaluation for mitral valve surgery. An echocardiogram had demonstrated left atrial and ventricular enlargement and significant mitral regurgitation with an enlarged valve annulus. Angiography results showed a very large aorta to left atrial shunt through an unsuspected intralobar sequestration. Lobectomy with removal of the sequestration resulted in significant improvement in cardiac chamber size and function over a 2.5-year follow-up period, thus obviating the need for cardiac surgery and removing a potential source of infection. Careful evaluation of chest imaging studies will lead to the correct diagnosis and treatment in patients with pulmonary sequestration who are thought initially to have primary cardiac disease.