Triple reinforcement of bronchial stump.

Various methods are used to prevent bronchopleural fistula following anatomical lung resection, as bronchopleural fistula constitutes a life-threatening complication. Pleural flaps are less vascularized, whereas an intercostal muscle flap, although well vascularized, does not offer enough strength for repair. We describe here the use of pleural flaps to strengthen a bronchial closure and cover the defect. Subsequently, an intercostal muscle flap is buttressed over the bronchial stump.

Pulmonary edema during repair of mycotic aneurysm of descending thoracic aorta, in postpartum period.

Infective endocarditis is uncommon during pregnancy. The difficulty in diagnosing infective endocarditis during pregnancy, may increase the likelihood of development of complications like a mycotic aneurysm of the descending thoracic aorta. We describe a case of mycotic aneurysm in the postpartum period, as sequel to delayed diagnosis; who developed pulmonary edema during its repair.

Superior mesenteric artery injury during en bloc excision of a massive left adrenal tumor.

Superior mesenteric artery (SMA) injury is a rare event during abdominal surgery. We report the first case of inadvertent injury of the superior mesenteric artery during surgery of a large malignant adrenocortical tumor with inferior vena cava thrombus. The cause of inadvertent injury was anatomical distortion of the great vessels due to the massive nature of the tumor. The case was managed successfully by immediate end-to-end anastomosis of the superior mesenteric artery.

Myocardial protection by nicorandil during open-heart surgery under cardiopulmonary bypass.

BACKGROUND: To evaluate the myocardial protective effect of nicorandil when used as an adjuvant to cold hyperkalaemic cardioplegia in open-heart surgery. METHODS: Patients who underwent surgery under cardiopulmonary bypass (CPB) for mitral valve replacement (MVR, 23 patients) or coronary artery bypass grafting (CABG, 24 patients) were entered in a double-blind study. The patients were randomized to a nicorandil Group (N) or placebo Group (P). Nicorandil 0.1 mg kg-1 (Group N), or normal saline (Group P), were administered at three time points: (1) after aortic cannulation, but prior to going on CPB, (2) 5 min before aortic cross-clamping and (3) 5 min before reperfusion. The following variables were studied: (a) time until electromechanical arrest after cardioplegia administration (Tarrest), (b) time until return of electromechanical activity after aortic cross-clamp removal (Trecovery), (c) incidence of postoperative myocardial infarction or low output syndromes (d) dysrhythmias requiring intervention after aortic cross-clamp removal and (e) haemodynamic changes after nicorandil administration. RESULTS: The Tarrest after cardioplegia administration was significantly faster in nicorandil group in both MVR and CABG patients (P 75 IU L-1 in MVR patients was significantly lower in the Group N than in placebo patients (P < 0.05). However, in CABG patients there was no such significant difference. The incidence of dysrhythmias requiring intervention after aortic cross-clamp removal was also less in Group N. Administration of 0.1 mg kg-1 boluses of nicorandil did not cause significant haemodynamic changes or precipitate dysrhythmias in any patient. CONCLUSION: Nicorandil enhances the myocardial protective effect of cold hyperkalaemic cardioplegia in cardiac surgery patients.

Arterial oxygenation changes in valvular heart disease patients with cardiomegaly in different recumbent positions.

BACKGROUND AND OBJECTIVE: We studied the effect of different recumbent positions (supine, left and right lateral decubitus), on arterial oxygenation in 42 valvular heart disease patients planned for cardiac surgery. All patients had cardiomegaly (cardiothoracic ratio > or = 0.5) in their chest X-rays. Their left ventricular end-diastolic diameter was also noted from the preoperative echocardiogram. METHODS: Arterial blood gas analysis was performed in supine, left and right lateral positions after keeping the patient in a given position for 15 min. During this period all patients received 35% oxygen supplementation. RESULTS: Arterial oxygen tension and haemoglobin saturation were significantly higher in the right lateral position (PaO2 = 120.6 +/- 29.5 mmHg, SaO2 = 98.1 +/- 1.4%) than in supine (PaO2 = 111.0 +/- 30.6 mmHg, SaO2 = 97.6 +/- 2.2%) and left lateral positions (PaO2 = 109.7 +/- 32.0 mmHg, SaO2 = 97.6 +/- 1.7%; mean +/- SD; P 0.05). The change in PaO2 and SaO2 with change of posture from left to right was significantly related to left ventricular end-diastolic diameter (r = 0.50 and r = 0.63, respectively; Pearson correlation). Repeated measures of analysis of variance with left ventricular end-diastolic diameter as a covariate showed a significant change in arterial PaO2 with posture (P = 0.011). CONCLUSION: Right lateral posture improves arterial oxygenation in the valvular heart disease patient with an enlarged left ventricle. In the preoperative period, these patients may benefit from a right lateral posture when lying in bed.

Closed mitral valvotomy for mitral restenosis: experience in 113 consecutive cases.

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 343 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years, Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results.