Surgery of very late intrathoracic esophgeal ruptures and perforations

Objective: The reasons of delay and a more selective management of 7 unusually late esophageal disruptions is evaluated in this study. Material and methods: In case of a 13 day-old rupture, left transthoracic debribement, primary repair with hiatusplasty was done. In a 6 week-old postpneumonectomy leak, esophageal exclusion, fenestration, chemotherapy and Roux-en-Y bypass was performed. Closure with serratus anterior flap was used in a small esophageal leak with empyema which occured 4 months after pneumonectomy. In a iatrogenic, 9 day-old esophageal injury, suture, than Urchel type temporary exclusion was carried out. In a 6 week-old iatrogenic leak with localised empyema, Urchel-Ergin type exclusion with thoracostomy was used. As a first step esophageal exclusion and than decortication was performed in a 13 day-old rupture with empyema,followed by substenal colonic bypass 2 months later. In a 7 day-old transfixion esophgeal wound, suture with drainage was performed. The patient with closed esophagus was lost, for irreversibile sepsis. Results. Recovery time was 9 to 28 days. Conclusion: Even in such unique esophageal disruptions individual approach prove to useful.

The valve-preserving operations on a chordo-papillary continuum in a mitral valve prosthesis

Objective. Studying of morphometric indices and contractility of left ventricle in various variants of preservation of chordo-papillary continuum in late period after the mitral valve prosthesis. Materials and methods. Analysis in 634 patients with isolated mitral valve failure, who were surgically treated from Sept. 1 2005 till Jan. 1 2007, was conducted. While the mitral valve prosthesis the chordo-papillary continuum was conducted, using preservation of the mitral valve posterior flap (41 patients) and simultaneous translocations of chordo-papillary muscles of anterior flap and preservation of posterior flap of a mitral valve (57 patients). Results. While comparing morphometric indices of left ventricle in left ventriculomegaly on a hospital stage and in late postoperative period when complete excision of a mitral valve in its prosthesis was performed, and when posterior flap was preserved, and simultaneously the posterior and anterior mitral valve flaps the improvement of the indices was observed, as well as normalization of a contractile function of left ventricle if a subvalvular space is preserved. Conclusion. Preservation of chordo-papillary continuum while performing the mitral valve prosthesis improves morphometric indices and contractility of left ventricle on a hospital stage and in late follow-up period.

Hip disarticulation with pedicled total leg fillet flap for recurrent fungating sarcoma

Soft tissue sarcomas may be treated with limb-sparing procedures in the majority of cases; however, certain cases involving significant tumor spread and fungation may call for amputation. In the thigh, hip disarticulation typically involves a pedicled gluteus maximus flap or a pedicled anterior quadriceps flap. In this case report, we describe a rare situation in which the anterior flap, posterior flap, and adductor flap musculature were contaminated with tumor; therefore, a hip disarticulation was performed applying a pedicled total leg fillet flap for closure. Eighteen months after treatment, the patient continues to have no local recurrence of disease, a stable flap site, and ambulates with a walker. We present this amputation and closure method as a potentially effective modality in treating extensive oncologic disease of the proximal lower extremity.

Conjunctival bleb compression sutures: An effective method of addressing hypotony after trabeculectomy or trabeculectomy-related procedures

Purpose: Over-filtration is a well-known complication of trabeculectomy and related procedures, especially with adjunctive antimetabolites. Secondary hypotony can result in reduced visual acuity and compromise long-term surgical success. Persistent hypotony requires intervention and we describe an effective adaptation of placing conjunctival compression sutures directly over the scleral flap. Methods: A retrospective consecutive case series of all patients who underwent conjunctival compression suturing from 2012 to 2014 at Manchester Royal Eye Hospital, UK. Under sub-tenon’s anaesthesia, two 9/0 nylon figure-of-eight transconjunctival sutures were placed horizontally across the bleb: the first over the anterior flap/ostium and the second over the posterior flap edge to reduce flow through the trabeculectomy flap. Results: A total of 10 patients underwent conjunctival compression suturing, and all patients had successful reversal of hypotony and symptom resolution within 1 week with corresponding clinical improvement. Intraocular pressure control was maintained without topical pressure-lowering agents in seven patients (median = 10 mmHg, range = 7–12 mmHg) with a median follow-up of 35.9 months (range = 11–61 months). Two patients required topical therapy to maintain intraocular pressure ≤ 14 mmHg and one patient’s hypotony returned after 10 months but remained untreated due to pre-existing poor vision. No patients required a return to theatre. Conclusion: This series demonstrates that conjunctival compression sutures can successfully provide long-term control of trabeculectomy-bleb-related hypotony. This technique offers an effective alternative for glaucoma surgeons in addressing post-trabeculectomy hypotony.