Right postero-lateral thoracotomy for atrial septal defect closure; a comparative analysis with median sternotomy

Introduction In a low risk procedure like ASD closure Right Posterolateral thoracotomy approach aims at the cosmetic results as compared to median sternotomy. This paper illustrates our approach for a standardised Right Posterolateral thoracotomy in ostium secundum ASD repair and the analysis of the outcome. Methods Right Posterolateral thoracotomy (RPLT) was offered as a cosmetic alternative for atrial septal defect (ASD) closure in children, and selected adult patients below 30 years with lean body build. A retrospective study comparing these patients with median sternotomy approach during the same period (2000–2003) was performed. Exclusion criteria included preoperative diagnosis of complex ASD, obesity and chest wall deformity. Common variables were considered for analysis. Results There were 96 patients (66 females and 30 males) with an average age of 13yrs (range 3 to 27 years) in RPLT group and 225 patients (95 females and 130 males) with average age of 36 years (range 2 to 46 years) in sternotomy group. Extra corporeal time was 32 minutes (28 to 45) and aortic cross clamp time was 14 minutes (8 to 36) in RPLT while the values were 46 minutes (37 to 90) and 22 minutes (18 to 36) in Median sternotomy approach. Blood loss in postoperative period was 160 ml (20 ml to 400 ml) in thoracotomy group compared to 210 ml (40ml to 600 ml) in sternotomy group. There was no mortality or recurrence after repair of ASD during the follow-up. Significant postoperative morbidity was persisting pain and shoulder movement restriction in 12 patients. The scar was cosmetic in RPLT. Conclusion In selected patients with lean body build Right posterolateral thoracotomy is suitable for ostium secundum atrial septal defect closure. The final appearance has definite cosmetic advantage over sternotomy. Presented at the 50^th Annual Meeting of IACTS, New Delhi, Feb., 2004.     

Laparoscopic Cholecystectomy in Cirrhotic Patients

Background and Objectives:

Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan.

Methods:

From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study.

Results:

Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8±0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2±32.54 minutes.

Conclusion:

Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.     

Thromboprophylaxis in laparoscopic abdominal surgery

Background: Since the introduction of laparoscopic cholecystectomy, there has been a great concern regarding the increased risk of thromboembolism following laparoscopic surgery. However, in the absence of clear guidelines, the use of thromboprophylaxis in laparoscopic abdominal surgery is controversial. Methods: The evidence for and against routine and selective thromboprophylaxis in patients undergoing laparoscopic abdominal procedures was reviewed based mainly on published British and Danish surveys, together with the author's own survey. An attempt was made to come up with a generally‐accepted protocol for thromboprophylaxis in laparoscopic surgery. Results: Less thromboembolic events were encountered by laparoscopic surgeons who adopt routine thromboprophylaxis. More thromboembolic events following laparoscopic abdominal surgery were encountered by surgeons adopting selective thromboprophylaxis policy. Conclusion: Routine thromboprophylaxis seems to be more effective in protection against thromboembolism. However, this warrants further confirmation by prospective randomized trials.      

Versatility of the distally based superficial sural flap for reconstruction of lower leg and foot in children

Twenty children are presented after undergoing a distally based superficial sural flap for coverage of defects at the lower leg and foot. The age of the patients was between 1 and 12 years. Fifteen patients had trauma to the lower leg, with eight of them having associated injuries. Three had postburn contracture and two had pressure sore. In 14 cases, the flap was used as a fasciocutaneous flap, whereas in six cases it was used as a fascial flap covered with a skin graft. The flaps were used to cover the defects from the dorsum of the foot distally up to the mid third of tibia proximally. The mean follow-up was for a period of 2 years. Even though free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children, the distally based superficial sural flap has the advantage of being easy to perform, with short operating time, minimal donor side morbidity, and preservation of major arteries of the leg.     

Spilled Gallstones: the Source of an Enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.     

Cerebellar tuberculoma mimicking posterior cranial fossa tumour

A young girl presented with history of prolonged fever, vomiting and headache. CT scan of brain revealed a space occupying lesion in posterior cranial fossa with moderate hydrocephalus. Surgery was performed and histopathology report confirmed the lesion as tuberculous. Patient showed smooth postoperative recovery and complete remission of complaints on antituberculous treatment for one year and regular follow-up.     

Frequency of dual tuberculosis/human immunodeficiency virus infection in patients presenting at tertiary care centers at karachi

Objective: To determine the frequency of dual infection of Tuberculosis and Human Immunodeficiency Virus (HIV) and document the sexual practices of infected patients. Design: Cross-sectional study. Place and Duration of Study: Medical Unit-IV of Civil Hospital, Karachi, Pakistan, in collaboration with Sindh AIDS Control Program at Services Hospital, Karachi, from January 2003 to December 2004. Patients and Methods: Patients were recruited in the study at both centers and tested for both HIV and TB if any one disease was identified. Diagnosis of TB was based on positive sputum AFB smear / caseous granulomatous lesion on histopathology. Diagnosis of HIV was based on positive anti-HIV serology by LISA technique. A questionnaire was also administered to all the study participants regarding demographics, sexual practices, blood transfusion and intravenous drug abuse. Results: A total of 196 patients of HIV and TB were screened for the presence of dual infection (TB/HIV). Dual infection was present in 38 (19.39%) of patients. Out of 126 patients of HIV, evidence of TB was detected in 38 (30.16%). During the same duration, 70 patients of tuberculosis were screened for HIV and none was tested positive for HIV. History of illicit sexual relationship was found in 121 (96.03%) patients and 5 of these were homosexuals. Conclusion: Dual infection was present in patients of HIV with TB but vice versa was not documented in this study.     

The reverse epidemiology of plasma total homocysteine as a mortality risk factor is related to the impact of wasting and inflammation.

BACKGROUND: The reason(s) for the apparently paradoxical 'reverse' association in end-stage renal disease (ESRD) patients in whom a low, rather than a high, total plasma total homocysteine (tHcy) level is an indicator of poor outcome remains unclear. The aim of this study was to examine whether the inverse association maintains, mitigates or reverses after comprehensive multivariate adjustment for the presence of wasting and inflammation as well as other potential confounders. METHODS: We studied 317 ESRD patients starting dialysis therapy. Fasting blood samples were taken for the analyses of tHcy, serum albumin, C-reactive protein (CRP), serum creatinine and plasma folate. Nutritional status was assessed by subjective global assessment (SGA). Survival was followed for up to 66 months; 105 patients died. RESULTS: Using Kaplan-Meier analysis, a low tHcy concentration (< or =30 micromol/l) was associated with higher all-cause and cardiovascular (CV) mortality (P < 0.05). Using Cox proportional analysis adjusting for age, gender, glomerular filtration rate = GFR, cardiovascular disease = CVD, plasma folate, total cholesterol and diabetes mellitus, the all-cause and CV mortality still tended to be high for patients with low tHcy. Adding nutritional and inflammation markers (Body mass index = BMI, SGA, serum creatinine, serum albumin and CRP), a low tHcy level was no longer associated with higher mortality but a trend for high tHcy was observed. CONCLUSIONS: The link between wasting inflammation and a low tHcy appears to be responsible for the reverse association between plasma tHcy and clinical outcome in ESRD patients. After adjustment for confounders including nutritional and inflammation markers, a trend towards increased death risk for high, rather than low, tHcy levels was apparent after adjustment.