Spontaneous migration of a bullet in the cerebellum--case report.

A 15-year-old boy presented with a gunshot wound in the left cerebellar hemisphere. He was confused and left cerebellar signs were noted. The patient underwent the first surgery for debridement of the entry wound in the left parietal region and second surgery to remove the bullet. However, the bullet could not be located via a left unilateral suboccipital craniectomy in the park bench position, because it had migrated to the opposite side due to the effects of gravity in just a few hours. Skull radiography obtained just before the third surgery showed that the bullet had returned to the left side, and it was removed easily via the previous craniectomy in the sitting position. The clinical course suggests that in removing a bullet, skull radiography or computed tomography should be obtained just before surgery, or even intraoperatively, and that those findings should be the basis for the surgical procedure and operative position.     

Medical-surgical aspects of left main coronary artery disease.

Disease of the left main coronary artery compromises circulation to the major part of the left ventricle and thus threatens massive myocardial infarction and sudden death. Cardiac catheterization and coronary bypass surgery, in previous reports, have been associated with high mortality and morbidity rates. We report 50 patients with over 50 per cent narrowing of the left main coronary artery. The clinical pattern in these patients was variable and a left main coronary artery lesion could not be predicted before coronary angiography. There was only one death during cardiac catheterization. One patient died while waiting for elective surgery. Coronary bypass surgery was performed in 42 patients; one died during surgery. Forty-one patients are alive at 2 to 39 months follow-up (mean, 19 months). Thirty-six patients are asymptomatic or have minimal symptoms. Compared to the prognosis in patients with left main coronary artery stenosis treated medically, coronary bypass surgery performed on urgent basis offers a much better prognosis. Both coronary angiography and bypass surgery can be performed in these patients with a very low risk.     

Iatrogenic diaphragmatic hernia following partial resection of the lung via video-assisted thoracoscopy

We report a case of iatrogenic diaphragmatic hernia following partial resection of the left lung via thoracoscopic surgery. A female in her 60s underwent partial resection of the left lung via thoracoscopic surgery on suspicion of primary lung cancer. The pathological finding was granuloma. Four months after surgery, she experienced pyrosis, and her radiograph showed a gastric bubble in the left thorax. Coronary-section computed tomography demonstrated that the gastric fundus had pushed into the left thorax. We performed elective video-assisted thoracic surgery because she did not show any symptoms. After the adhesiolysis, the herniated stomach was returned into the abdominal cavity, and the hernial orifice of the diaphragm was directly sutured. The postoperative course was uneventful, and the patient was discharged on the 12th postoperative day and is doing well. We should consider the possibility of iatrogenic diaphragmatic hernia following thoracic surgery during which an invasive technique involving the diaphragm was undertaken.     

A case of surgically treated left atrial myxoma following acute multiple embolism including cerebral embolism

The patient was a 59-year-old female who was admitted to the hospital due to acute pain of bilateral legs, a numbness of right hand and anarthria. Angiography of extremities revealed total occlusion of right ulnar artery, left radial artery and bilateral popliteal arteries. Brain MRI revealed multiple small infarctions. Echocardiography revealed a mass in the left atrium. She was diagnosed as multiple embolism including cerebral embolism caused by left atrial myxoma. Open heart surgery immediately after the attack is generally considered contraindicated due to problems of hemorrhagic infarction or brain edema. But, relapse of embolism may deteriorate the condition and miss the timing of surgery. Thus we performed removal of left atrial myxoma 4 days after the attack. The postoperative course was uneventful. This is a few report about open heart surgery immediately after the attack. We report about the indication and the optimal timing of open heart surgery following cerebral embolism.     

Laparoscopy-assisted aortobifemoral bypass through the transperitoneal retrorenal approach

The aim of laparoscopic vascular surgery in the aortoiliac segment is to replicate the excellent outcomes of open aortic surgery while providing the advantages of minimally invasive surgery. We report the case of a 49-year old man with disabling hip claudication and rest pain in his left lower extremity. On examination the patient had reduced right femoral pulse and absent pulses in his left lower extremity. Angiography revealed occlusive disease in the left aortoiliac segment and right common iliac artery stenoses. Laparoscopic aortobifemoral bypass was planned. The surgical technique included 70 degrees -right lateral decubitus position and retrorenal retrocolic dissection from the left common iliac artery to the left renal vein. Minilaparotomy consisted of aortic clamping, arteriotomy, and end-to-side aorto-prosthetic anastomosis with Dacron graft. Time to extubation was 5 hours; peristalsis was recovered 72 hours after surgery. The patient was discharged from hospital after cardiologic assessment 9 days after surgery.     

Pre-aortic left renal vein compression syndrome (Magoss and Walshe syndrome)

A case of a pre-aortic left renal vein compression by the aorta is reported. The clinical presentation was characterized by the left flank pain varying with body position. Renal venography was crucial for the diagnosis of this lesion. The left renal vein was successfully decompressed by ovarian vein-vena cava shunt surgery. The patient's left flank pain subsided after the surgery. This is the first reported case of a left renal vein compression syndrome by the aorta following the nephrotic syndrome.     

Surgical treatment of the left circumflex coronary artery from the pulmonary artery in an adult patient

We report an exceptional case of ischemic heart disease due to the origin of the left coronary circumflex artery from the pulmonary artery in a 50-year-old woman. She had undergone surgery for aortic coarctation when she was 16 years old. This abnormality was associated with other congenital defects such as tunnel subaortic stenosis, small aortic valve annulus, numerous left ventricular false tendons, and aortic bicuspid valve. Cardiac surgery verified the origin of the left circumflex from the pulmonary artery. The left internal mammary artery was positioned on the obtuse marginal coronary branch. Her clinical state was moderately improved 3 months after surgery.     

Excision of a left atrial myxoma via a minimally-invasive technique: a possible routine access

We would like to present our experience of surgical excision of intracardiac tumors using a video-assisted minimally-invasive cardiac surgery (MIC) technique. An 83-year-old female patient received video-assisted cardiac surgery for excision of a left atrial tumor. The surgery was performed through a right anterior submammary minithoracotomy and guided by video-assisted endoscopic techniques by projected images on a video monitor while under femoro-femoral bypass. The myocardium was protected by single-dose antegrade crystalloid cardioplegia. The tumor was excised completely recording a 61-minute bypass time and a 103-minute total operative time. Histopathological examination revealed left atrial myxoma. Transthoracic echocardiography examination showed good ventricular function and the absence of residual tumors. The patient was satisfied by the cosmetic healing of the wound and was discharged eight days after the surgery. Video-assisted MIC surgery is technically feasible and could be applied as a routine access in all left atrial tumors without the fear of inadequate intraoperative exposure and its drawbacks.     

结肠灌洗用于急诊左半结肠一期手术48例临床分析

为探讨结肠灌洗在急诊左半结肠一期手术中的应用效果,对48例行结肠灌洗、左半结肠一期手术患者资料进行回顾性分析。结果显示,本组患者均未实施肠造口,全部一期治愈,无吻合口漏、腹腔严重感染等并发症。结果表明,术中结肠灌洗、急诊行左半结肠一期手术具有可行性,避免了肠造口的发生,具有操作简便,成本低廉,术后并发症少等优点。     

Coexistence of hyperplasia of renomedullary interstitial cells and juxtaglomerular cells after acute occlusion of renal artery

A left renal artery aneurysm was found in a 45-year-old normotensive man. In an attempt to evade the possible occurrence of aneurysmal rupture, aneurysmectomy in addition to left renal biopsy (first surgery) was performed. This vascular operation led to a virtually complete renal artery stenosis concomitant with the development of hypertension. The renin-angiotensin-aldosterone system and levels of plasma prostaglandins were also increased following this failed surgery. Reconstruction of the affected renal artery was technically so difficult that left nephrectomy was carried out (second surgery). Renal specimens obtained at the first surgery revealed no histological abnormalities. Discriminating histological findings of the kidney obtained at the second surgery were remarkable; hyperplasia of the juxtaglomerular cells producing renin and hyperplasia of the renomedullary interstitial cells which had pecularities similar to cells known to secrete renal prostaglandins. High levels of the renin-angiotensin-aldosterone system and plasma prostaglandins after the first surgery were reduced following the second surgery. It is suggested that acute constriction of the renal artery led to a hyperplastic change of the juxtaglomerular cells and the renomedullary interstitial cells and stimulated an inappropriate release of renin and renal prostaglandins.     

Transbrachial coil occlusion of the large branch of an internal mammary artery coronary graft

Percutaneous transbrachial insertion of two complex coils into the intercostal branch of the left internal mammary artery resulted in the relief of severe angina in a 45-year-old man who had coronary artery bypass surgery 2 years before. The diagnosis of coronary artery steal was made clinically. This case illustrates the importance of recognizing coronary steal in patients who redevelop angina after coronary artery surgery with the use of an incompletely prepared left internal mammary artery as a conduit. Brachial or radial artery should be preferred to reach left internal mammary artery (LIMA) for cannulation easily. The preoperative angiographic imaging of LIMA is important to detect the side branches and their sizes. The patient was treated without the need for further surgery.     

Beating heart coronary artery bypass surgery after orthotopic heart transplantation

Beating-heart coronary artery bypass surgery was performed in a 52-year-old man with accelerated transplant coronary artery disease 10 years after orthotopic heart transplantation. Transplant coronary artery disease was first detected in the left circumflex coronary artery 9 years after transplantation. Rapid progression to triple vessel disease occurred within 1 year, and the patient developed worsening symptoms of shortness of breath and chest pain. He underwent off-pump "beating heart" left internal mammary artery to left anterior descending coronary artery bypass surgery. The circumflex coronary artery was not graftable due to diffuse and truncated small vessel disease. His postoperative course was uneventful and he was discharged on the fifth postoperative day. Coronary angiography 3 months after the surgery revealed a widely patent left internal mammary artery to left anterior descending artery bypass. He is alive and symptom free more than 1 year after his surgery.     

Surgical Treatment of a Superior Sulcus Tumor in a Patient with Idiopathic Thrombocytopenic Purpura: Report of a Case

We herein report a resection of a superior sulcus tumor in a patient with idiopathic thrombocytopenic purpura. A resection of the left upper lobe of the lung, left subclavian artery, and left first to third ribs, as well as a reconstruction of the left subclavian artery, were performed. Postoperative hemorrhaging was controlled due to preoperative high-dose intravenous immunoglobulin therapy and a platelet transfusion both during and following surgery. The resected tumor was diagnosed to be a pulmonary pleomorphic carcinoma, which was pathologically determined to be T3N0M0-Stage 2B. The patient remained in good condition for 20 months following the surgery; however, he eventually died due to bone metastases.     

Left ventricular reduction in a Jehovah's Witness

For Jehovah's Witnesses with severe heart failure, left ventricular reduction surgery may be a satisfactory alternative to cardiac transplantation. Compared with transplantation, left ventricular reduction surgery can involve less blood loss thus decreasing the need for blood-volume replacement. More importantly, left ventricular reduction surgery obviates the need for a donor organ.     

Predictors of residual tricuspid regurgitation after mitral valve surgery

BACKGROUND: Whether preoperative tricuspid regurgitation (TR) will regress or progress late after surgery is unknown. The aim of this study was to evaluate predictors of significant TR late after mitral valve surgery. METHODS: A retrospective analysis was performed on a total of 174 patients who underwent mitral valve surgery without tricuspid valve surgery. Preoperatively, 46 patients (26%) had 2+ TR, and 128 patients (74%) had 1+ or less TR. Postoperative 3+ TR was considered significant TR. Variables were used to evaluate predictors of TR development by univariate or multivariate analysis. RESULTS: The mean follow-up was 8.2 years (range 1.0 to 14.5 years) after surgery. There was progressive TR (3+ or more) in 28 patients (16%) during the follow-up period. In univariate analysis, atrial fibrillation, rheumatic etiology, huge left atrium, left ventricular dysfunction, and preoperative 2+ TR were significant risk factors for TR development. Multivariate analysis identified preoperative 2+ TR, atrial fibrillation, and huge left atrium as statistically significant predictors for late TR after surgery. CONCLUSIONS: Aggressive repair of accompanying TR should be undertaken at the time of initial surgery in patients with huge left atrium or atrial fibrillation, even if preoperative TR is 2+.     

Successful treatment with bypass and interventional surgery for a ruptured pseudo carotid artery aneurysm after transsphenoidal surgery: a case report

We report case of a patient who suffered a pseudo internal carotid artery (IC) aneurysm following transsphenoidal surgery. He was successfully treated with bypass surgery and IC occlusion involving the pseudoaneurysm using Guglielmi detachable coils (GDCs). This 50-year-old man with recurrent FSH-releasing pituitary adenoma suffered profuse arterial bleeding during transsphenoidal surgery. The hemorrhage was managed, using oxidized cellulose with bio-bond. His postoperative course was uneventful, but, he developed massive epistaxis 20 days after surgery. Cerebral angiograms showed a pseudoaneurysm arising from the C4 portion of the left IC. He could not tolerate the balloon occlusion test. Using GDCs, we immediately performed left IC occlusion involving the pseudoaneurysm followed by bypass surgery between the left EC and the left middle cerebral artery. Postoperative angiograms showed that the pseudoaneurysm was completely occluded and the bypass was fully patent. When massive arterial bleeding is encountered during transsphenoidal surgery, the patient should be carefully monitored to detect early the development of a pseudoaneurysm. When such an aneurysm is found or has ruptured, interventional surgery has proved effective in the management of this complication.     

Acute ventricular hemorrhage in adults with hydrocephalus managed by corpus callosotomy and fenestration of the septum pellucidum. Report of three cases.

Three patients with hypertension-induced basal ganglia or thalamic hemorrhage and ventricular rupture underwent corpus callosotomy and fenestration of the septum pellucidum. A patient with a left thalamic hemorrhage underwent surgery on an emergency basis and made a complete physical recovery, although she retained mild psychomotor deficits. Another patient with a large right basal ganglia hemorrhage who also underwent surgery on an emergency basis retained a spastic left hemiparesis without evident psychomotor deficits. The third patient with a left thalamic and basal ganglia hemorrhage, who was initially awake and then lapsed into stupor days later, underwent surgery, but did not recover consciousness. Hydrocephalus was reversed and effectively controlled in all three patients without having to perform a shunt placement procedure.     

Arterioureteral fistula. An unusual cause of aortofemoral bypass infection. A case report

We report a case of arterioureteral fistula after aortobifemoral bypass surgery and prolonged bilateral double J stents due to ureteral stenosis. A 70-year-old woman presented with a non-tender mass in the left groin and a single episode of haematuria 2 months earlier. A Computed Tomography (CT) revealed a pseudoaneurysm of the left distal suture of the graft. Surgical repair was performed. Because of suspicion of infection the entire aortobifemoral graft was removed and replaced by an autologous venous aortofemoral bypass to the right groin and femorofemoral crossover bypass from the right to the left. During surgery an arterioureteral fistula could be visualized. The urologists performed a left nephroureterectomy of the afunctional left kidney. The further postoperative course was uneventful during the 10 months of follow up.     

A case of adult moyamoya disease progressed after vascular reconstructive surgery

We report an adult onset patient with moyamoya disease showing acute progress after contralateral vascular reconstructive surgery. A 47-year-old female developed cerebral infarction in the left corona radiata. A magnetic resonance (MR) angiography and a cerebral angiogram revealed severe stenosis extending from the terminal portion of left internal carotid artery (ICA) to the M1 portion. The right ICA showed slight stenosis. We performed direct bypass surgery (STA-MCA anastomosis) on the affected left side. MR angiography 1 month after surgery revealed the progressive stenosis of the C1 portion of the right ICA. While measurement of cerebral blood flow (CBF) showed a slight impairment of vascular reactivity to acetazolamide loading in the region of the right MCA, we continued without vascular reconstructive surgery for the right side because there was no ischemic attack. The patient had a transient sensory disturbance of the left upper extremity 16 months after surgery. MR angiography and a cerebral angiogram revealed more progressive stenosis extending from the right ICA to the M1 portion. CBF study showed a low CBF at rest and a negative response to acetazolamide loading in the region of the right MCA. Direct bypass surgery was performed on the right hemisphere. Follow-up study revealed an increment of rest CBF and improvement of vascular reactivity. We underlined the necessity for careful postoperation observation of progressive contralateral arterial stenosis using MR angiography and CBF study in adult onset patients with moyamoya disease.