The modified Blalock-Taussig shunt: a 6-year experience from a developing country.

Since 1992 we have performed the modified Blalock-Taussig shunt (MBTS) for cyanotic children in Libya. This retrospective study reviews our results as a developing country, comparing them with those in the literature, and makes suggestions to improve our results. Between May 1992 and May 1998, 94 children (58 males and 36 females) underwent 100 MBTSs in Mesallata Cardiothoracic Centre, Libya. The age ranged from 4 days to 15 years, (median 12 months) and 25 patients were neonates. Patients' weights ranged from 3 to 31 kg (median 6.4 kg). Eighty-nine shunts were performed on the left side and 11 on the right. A 6-mm polytetrafluoroethylene graft was used in 68 children and a 4-mm graft in 32 cases. Tetralogy of Fallot (TOF) comprised the majority of cases (63; 67%), the remaining 31 (33%) included tricuspid atresia (13), pulmonary atresia (9), univentricular heart complex (6), and others (3). Acute shunt failure occurred in 3 cases (2 with 4-mm and 1 with 6-mm grafts), all of which had not received perioperative heparin. Hospital mortality was 6% (6 patients); risk factors were neonates, a diagnosis other than TOF, and emergency surgery. There were 12 late deaths, 6 of which were due to sepsis. Follow-up was achieved in 82 of 88 early survivors for a period of 2 to 60 months (median 26 months). All surviving patients had subjective and objective improvement. We conclude that MBTS is an excellent palliative procedure for children requiring a systemic-pulmonary shunt in developing as well as developed countries. This series shows an early mortality rate comparable to that of other studies, but the late mortality is higher, mainly due to sepsis, which warrants further attention.

Intracavitary cardiac hydatid cyst and the wall sign criteria.

Cardiac hydatid is rare at any age, accounting for less than 2% of all hydatid disease. The case is discussed of a 48-year-old female with a cardiac hydatid cyst attached intracavitary in the posterior wall of the right atrium. The Echinococcus cyst grows very slowly and, unless located in a critical anatomic site, it takes many years to evolve. Since the introduction of two-dimensional echocardiography, more cases are being diagnosed. The cyst was discovered incidentally by X-ray computed tomography and confirmed by trans-oesophageal echocardiography utilizing the wall-sign criteria developed by the authors. The cyst was removed surgically and the patient recovered by medical therapy.

Resection of an intracardiac metastasis from malignant teratoma of the testis.

Nonseminomatous germ cell testicular neoplasm is a disease cured primarily by platinum-based combination chemotherapy. Operation is reserved for those patients who continue to harbor residual masses after chemotherapy. Locoregional lymph nodes and lungs are common sites for residual deposits. Intracardiac metastases are very rare. We report a case of successful resection of bilateral lung and single intracardiac secondary deposits from a malignant teratoma, treated by orchidectomy 6 years previously.

Operation for cavitating invasive pulmonary aspergillosis in immunocompromised patients.

Invasive pulmonary aspergillosis is a specific form of pulmonary Aspergillus infection that occurs almost exclusively in immunocompromised patients. It differs both histologically and in its clinical course from classic aspergillomas. During a 5-year period (1986-1990), 8 patients underwent resection for cavitating invasive pulmonary aspergillosis that developed as a consequence of neutropenia during chemotherapy for malignancy. There were no perioperative deaths and no complications. This contrasts with reports of operation for classic aspergillomas. Histologic examination of the resected specimens showed that cavitating invasive pulmonary aspergillosis differed from classic aspergillomas. They consisted of necrotic lung tissue invaded by fungus with separation from the surrounding lung so that the sequestrum had the appearance of a fungus ball. Pulmonary aspergillosis is a common complication of profound neutropenia. The first hemoptysis in this group of patients is often life-threatening. The excellent results of operation in our series of patients may be attributed to their young age, good pulmonary function, and limited operation. This has lead us to recommend early surgical intervention in invasive aspergillosis once cavitation develops.

Prophylactic minitracheotomy in lung resections. A randomized controlled study.

Thirty consecutive patients undergoing lung resections were randomized into two groups: Group A (n = 15) received minitracheotomy postoperatively and group B (n = 15) were control patients. Postoperative respiratory course was monitored by serial clinical assessments, chest x-ray examination, arterial blood gases, sputa bacterial cultures, and the patient's requirement and response to chest physiotherpy. The two groups were similarly matched in age (mean 58.5 years), smoking habits, pulmonary functions, and surgical procedures. Postoperative pulmonary complications of collapse/consolidation developed in 11 patients (two in group A and nine in group B) (p less than 0.03). Four patients (all in group B) required nimitracheotomy in addition to antibiotics and chest physiotherapy to treat their pneumonia. Chest physiotherapy requirement was less in group A than in group B, with a mean number of sessions of seven in group A and eight in group B and a mean total time of 92 minutes in group A and 112 minutes in group B. The mean duration of minitracheotomy was 4.13 days. Minor temporary symptoms resulted from the minitracheotomy in eight patients (42%) and included discomfort, voice changes, subcutaneous emphysema, and stridor. There was one case of long-term morbidity (5%)-skin scarring from wound infection at the site of the minitracheotomy. No postoperative deaths resulted. We conclude that the prophylactic use of minitracheotomy is safe and effective in decreasing postoperative respiratory complications in patients undergoing lung resections.

Broncho-oesophageal fistula of infectious origin.

A case of end stage pulmonary destruction secondary to adult onset broncho-oesophageal fistula of infectious aetiology is presented. Advanced bronchiectatic damage to the pulmonary parenchyma may be avoided by the maintenance of a high index of suspicion and a systematic approach to the diagnosis of recurrent lower respiratory tract infections.