Left Hemi Research Articles

Surgical Treatment of the Aortic Coarctation in Adults: Extra Anatomical Ascending-to-descending Aortic Bypass and Concomitant Procedures

Objectives: Aortic coarctation is defined as the narrowing of the aortic lumen secondary to hypertrophy of the posterolateral aortic wall’s media layer. The coarctation is locates between the junction from ductus arteriosus to the left subclavian artery and left hemi aortic arch. Aortic coarctation provokes many severe and lethal complications, such as severe aortic stenosis, aortic aneurysms, pseudoaneurysms, stroke, and premature coronary artery disease, unless it had not been repaired in the meantime the initiation of the symptoms. Methods: We presented the consecutive nine patients who underwent aortic coarctation open surgical repair between 2015 and 2020 which initiated ascending-to-descending aortic bypass and then concomitant operations for the secondary cardiac pathology such as ascending aortic aneurysm, Type A aortic dissection and sinus valsalva aneurysm required in some cases. Patients were a median age of 26 years old (range, 19–41 years). About 11% of the patients (n=1) presented to our emergency room with severe chest pain and acute Type 2 aortic dissection was diagnosed by the surgical team, and he underwent operation immediately. The supracoronary aortic replacement and ascending to descending aortic bypass procedures were performed sequentially. About 44% of the patients (n=4) were diagnosed as isolated aortic coarctation and only ascending –to- descending aortic bypass was performed electively. About 22% of the patients (n=2) had ascending aortic aneurysm without aortic valve pathology. These patients underwent supracoronary aortic replacement as concomitant procedure to ascending to descending aortic bypass. About 22% of the patients (n=2) had bicuspid aortic valve and sinus Valsalva aneurysm; therefore, the Bentall procedure was implemented concomitantly. Results: There were not any early deaths reported. Any neurologic complications including neither paraplegia nor stroke revealed during post-operative follow-up. About 88% of patients (n=8) were discharged with stable hemodynamic parameters in 2 weeks. About 11% of these patients (n=1) who underwent Bentall procedure concomitantly had third-degree atrioventricular block as a serious rhythm problem then a permanent pacemaker implanted. This patient had been discharged with stable hemodynamic parameters and pacemaker settings were controlled by the cardiology department. Conclusion: The extra anatomical ascending-to-descending aortic bypass is a safe and feasible method for the open surgical coarctation repair, and it provides concomitant procedures for other cardiac pathologies, which require open surgical treatment.

Myofibroblastic Sarcoma of the Maxillary Sinus: Very Rare Entity

Introduction: The Myofibroblastic Sarcoma is a recently discovered malignant tumor that mainly affects the face and neck region, but it occurs most often in the tongue and oral cavity. However, involvement of the maxillary sinus has only been reported a few times in the literature. It is a slowly growing neoplasm with a high recurrence and metastasis risk.  Case Presentation: 18 years old female patient, admitted for a painless mass of the left hemi palate increasing progressively in volume evolving since 5 months, associated to a left nasal obstruction and purulent rhinorrhea. Once in our department, she underwent a facial CT scan, followed by a facial MRI, which showed a tissue process centered primarily on the left maxillary sinus, causing lysis of the inferior wall and bulging of the hard palate on the left side . The surgical decision involved combining an endoscopic and external approach, and was supplemented by radiation therapy. The follow up demonstrated a successful outcome. the patient did not present any recurrence or distant metastasis.  Conclusion: The key lessons are the essential role of imaging in diagnosing and treating LGMS , as well as the crucial role of postoperative radiotherapy in preventing recurrence even though this subject is still controversial.

The Use of the Galea Flap for the Reconstruction of Forehead Defects

The forehead, a vital anatomical unit of the face, is delimited by the anterior hairline superiorly and by the nasal root, eyebrows, and a horizontal line through the lateral canthus inferiorly. Malignant tumors like basal cell carcinomas frequently afflict this region, necessitating meticulous reconstruction techniques to preserve aesthetics and functionality. This article presents an in-depth exploration of the galea flap graft’s efficacy in addressing tissue defect on the forehead, especially in cases of basal cell carcinomas. The surgical procedure involves a wide excision with a 1 cm safety margin, including the frontal muscle and periosteum, followed by exposing the frontal bone. A meticulous approach is taken in tracing the midline, marking the hairline, and planning the left hemi coronal incision to ensure optimal outcomes. The galea flap, vascularized by branches of the superficial temporal artery, is meticulously lifted and transposed downwards to cover the tissue defect, while ensuring the viability of the flap. Postoperative monitoring reveals no signs of cutaneous or vascular damage, with preserved sensory and motor functions attributed to the preservation of the frontal branch of the facial nerve. The discussion delves into the intricate anatomy of the forehead, emphasizing its vascularization, innvervation, and aesthetic subunits such as the glabella and eyebrows. Various surgical techniques, including direct suturing, directed healing, skin grafts, advancement flaps, and two-stage scalp flaps, are examined in light of their efficacy and limitations in forehead reconstruction. The galea flap emerges as a preferred option due to its reliable vascular supply, ease of lifting, and versatility in covering tissue defects while preserving aesthetics. Future research directions are suggested, focusing on refining surgical techniques to achieve optimal outcomes in forehead tissue reconstruction, balancing esthetic results with functional integrit.

Poorly differentiated papillary thyroid carcinoma in a 5-year-old girl: a case report

BackgroundThe incidence of thyroid cancer has been increasing among the population less than 20 years of age, especially during the second decade of life. Differentiated papillary thyroid cancer is the most common pathology in children. It usually presents with thyroid nodules with or without cervical lymphadenopathy. Thyroid nodules carry a considerable risk of malignancy in children.Case presentationWe herein report a 5-year-old girl with poorly differentiated papillary thyroid cancer which is an extremely rare finding at this age. The patient underwent right thyroid lobectomy followed by left hemi thyroidectomy and right central and lateral neck dissection. Pathologic examination revealed a poorly differentiated papillary thyroid carcinoma with nodal deposits.ConclusionIt is essential to raise awareness of proper evaluation and management of thyroid nodules at such an age.

A missed mummified twin abdominal pregnancy: A case report

Background: Abdominal pregnancies are rare pathologic ectopic pregnancies that occur in 1:10,000-30,000 pregnancies. Implantation sites include the pelvic and abdominal peritoneum, uterine surface, omentum, and abdominal organs, including the intestine, liver, spleen, diaphragm, and large blood vessels. They are frequently missed antenatally, especially because there are no specific clinical signs and symptoms for abdominal pregnancy making diagnosis difficult. Diagnosis is often made during cesarean delivery. Ultrasonography modalities have high diagnostic errors between 50 and 90%. Case presentation: A 41-year-old presented with copious purulent vaginal discharge that was mixed with blood and was foul-smelling for two months as a referral to the Kenyatta National Hospital. Abdominopelvic computed tomography revealed a heterogeneous lesion in the left hemi abdomen. Her last menstrual period was December 2022 with DMPA in the same month. Her PDT was negative. She was sick-looking and had a purulent vaginal discharge. Intraoperatively, 500 mls of serous fluid was observed, and abdominal pregnancy, approximately 24–28 weeks of gestation with mummified skull bone, brain tissue, ribs, and long bones of the lower and upper limbs in their multiples suggestive of twin gestation. The patient’s postoperative period was uneventful, and she was later discharged in good condition. Conclusion: Proper and timely diagnosis of abdominal pregnancy is required to improve outcomes, especially maternal outcomes. In this case, the pregnancy was fatal to the fetus, although maternal mortality have been reported. The diagnosis may come as a surprise finding intraoperatively theatre-like in this case and in some cases postemergency cesarean delivery for failed labor induction. The diagnostic modality of choice is ultrasonography, although our patient had ultrasound and computed tomography but ended up with a misdiagnosis because of the complexity of the diagnosis of abdominal pregnancy.

Left paratesticular mass mimicking polyorchidism: A case report

We report a rare case of primary scrotal lipoma in a 20-year-old patient which clinically mimics a left triorchidism. The patients presented with the left testicular swelling and the ultrasonography of the scrotum revealed an inhomogeneous hyperechoic mass with an inconclusive report. The left scrotal hemi exploration was planned, and intraoperatively, it was found to be a paratesticular mass with an equivalent size corresponding to the left testicle, separate from the left testicle. The histopathology confirms the lipomatous swelling. The post-operative period remains uneventful and the patient has been on follow-up for the past 1 year with no relapse.

Laparoscopic Surgery of an Isolated Splenic Hydatid Cyst in a 43- Year- Old Man: A Case Report

Introduction: Hydatid disease is a type of parasitic disease mainly affect the lungs and the liver and splenic hydatid cyst is a rare disease. We hereby present a rare case of splenic hydatid disease. Case report: A 43-years-old man with a history of left upper quadrant pain (LUQ) pain, anorexia, weakness, and weight loss was admitted to the surgery department in Iran. The imaging studies showed a cystic mass in the gastro-splenic ligament extending up to below the left diaphragm with adhesion to the spleen capsule and the fundus of the stomach caused focal elevation of this part of the diaphragm. A laparoscopic surgery was performed and splenic hydatid cyst with adhesion to the stomach and the left lobe of the liver and with penetration into the left hemi thorax was observed. Splenectomy, hepatectomy of the left segment of the liver, repair of diaphragmatic defect and stomach release was done. Conclusion: Splenic hydatid cyst surgery can be difficult and requires appropriate diagnostic evaluations and examination for adhesions and invasion to other organs.

Odontogenic Carcinoma with Dentinoid of the Left Maxilla

Abstract Introduction/Objective Odontogenic carcinoma with dentinoid is a very rare dentinoid producing odontogenic tumor with 10 cases reported in literature, and it is not currently defined by the World Health Organization. It has been described to have a locally aggressive and non-metastatic course with high level of recurrence after excision. Methods/Case Report We report a case of odontogenic carcinoma with dentinoid located in the left maxilla of an otherwise healthy, 22-year-old male. The patient initially endorsed left upper molar tooth pain for 2 months that led him to receive medical attention. Initial examination revealed a 3 x 2 cm firm, non-mobile and non-pulsatile lesion on buccal and lingual surface of the left maxilla with imaging revealing a 2.9 x 2.7 x 2.7 cm mixed radiolucent/radiopaque lesion in the posterior left maxilla with expansion on the buccal and palatal surfaces. Incisional biopsy of the left maxilla (soft tissue) was initially diagnosed as suspicious for osteosarcoma, which was later changed to odontogenic carcinoma with dentinoid. One year later, the mass had increased to 4.5 x 3 x 4 cm in size. Left hemi maxillectomy was performed, and the specimen was diagnosed with odontogenic carcinoma with dentinoid. Previously described histological features of clear cell change, low grade appearance, focal calcification, and dentinoid formation are present in our case. Our case is the first to describe glandular formation of the tumor cells. Results (if a Case Study enter NA) NA Conclusion The histopathological changes of our case reflect previously reported microscopic descriptions for this exceedingly rare tumor that is unclassified by the World Health Organization. It has been reported to occur in both male and female patients without predilection and a wide age range from 14-61 years. To our knowledge, this is the 11th reported case, and the 5th case described in the maxilla. Further studies, including NGS sequencing to determine genetic alterations, will be performed on our case to further elucidate pathophysiological mechanisms. Long term follow up with our patient will be attempted to determine tumor behavior.

Effectiveness of Motor Relearning Programme on Sit to Stand Performance Among Right and Left Hemiparesis Patients

OBJECTIVE: To compare the effectiveness of Motor Relearning Program (MRP) on sit to stand performance among right and left hemi paresis patients. Study design: Quasi experimental study design with two groups pre-test and post test. Participants: A total of 16 male right and left hemi paretic patients in the age group of 45 to 65 years participated in the study. The participants recruited were diagnosed with middle cerebral artery lesion with duration less than 3 weeks and a score of 1 on the Motor Assessment Scale for sitting to standing up item. The patients who satisfied inclusion criteria were conveniently assigned into 2 groups. Group A- right hemiparesis and Group B- left hemi paresis. Interventions: Motor Relearning Programme for sitting to standing for duration of 2 weeks (40 minutes/session, 5session/week, total 10 sessions). Outcome Measures: Measurements were taken using Sitting to standing functional item of Motor Assessment Scale (MAS) following 2 weeks of the training program. Results: Statistical analysis was done using the ‘t’ test, which showed a significant improvement in Motor Assessment Scale (MAS) for sitting to standing up item for both groups. But GROUP-A (Right hemi paresis) showed a more significant improvement than GROUP – B(Left hemi paresis) in Motor Assessment Scale (MAS) for sitting to standing up item. Conclusions: The findings of this study suggest Motor Relearning Programme improves sit to stand performance. And there was a significant difference in sit to stand performance between right and left hemi paresis patients following 2 weeks of Motor Relearning Programme. Keywords: Motor Relearning Programme, Sit to stand, Motor Assessment Scale, Hemi paresis.

397. LEFT PILLAR PINCHING TECHNIQUE FOR MINIMALLY INVASIVE REPAIR OF PARA-CONDUIT HERNIA

Abstract Surgical repair of the para-conduit hernia provides an increasing challenge in the era of minimally invasive oesophagectomy. The key principles are preservation of the gastric conduit and its right gatro epiploic vascular arcade, and durable closure of the defect. Of various methods, posterior crural repair is difficult without mobilising and risking and kinking the conduit, while anterior repair of a big defect requires the adjunct of a mesh which carries its own risks of infection or erosion. There is no consensus on the appropriate surgical technique. We propose that the Left pillar of the hiatus be pinched to provide an effective repair. This is safe as dissection and suturing is well away from the conduit and arcade. We find the left pillar to be adequately mobile to allow repair, and the sutures sit in the tendinous portion of the left hemi diaphragm to provide durability. We provide 2 videos to describe the key steps in this technique and demonstrate that this technique is effective in both small and large defects, and acute and chronic para-conduit hernia. Link: https://1drv.ms/v/s!Anu-cyBTuGbsgbxtX8aLf2P1YEPl9g?e=fXz7Pm. Please contact me, shantjog@gmail.com if this link does not work and I will explore an alternative method to share the video. Many thanks.

Recurrent Larnygeal Nerve Injury in Endoscopic Hemithyroidectomy

Objective: To find the frequency of recurrent laryngeal nerve damage in endoscopic thyroidectomy. Study design: Cross sectional descriptive study Place & Duration of study: Ward 25, Jinnah Postgraduate Medical Centre, Karachi, Pakistan from January 2018 to January 2021. Methodology: Eighty patients of solitary thyroid nodules who fulfill inclusion criteria were divided alternatively into endoscopic and open hemi thyroidectomy groups. Patients were assessed for recurrent laryngeal nerve injury in the evening and after 24 hours of surgery by quality of voice. Those patients whose voice is normal discharge on 2nd day while others follow fortnightly until 3 months. Results: There was no recurrent laryngeal nerve injury encountered in group A while in group B 4 (10%) transient recurrent laryngeal nerve injuries were encountered. All injuries were recovered within 3 months post operatively. Out of 4 recurrent laryngeal nerve injuries 3 (75%) on left side (left hemi thyroidectomy) while 1 (25%) on right hemithyroidectomy.2 (50%) recurrent laryngeal nerve injuries in patients when surgery time was approximately 3 hours. Conclusion: Endoscopic thyroidectomy is safe, feasible and emerging minimal invasive technique to remove the thyroid gland without visible scar. Keywords: Recurrent laryngeal nerve, Endoscopic thyroidectomy, Solitary thyroid nodule

Palpebral Reconstruction in a Secondary Ophthalmology Center in Mali: About a Case

Introduction: Significant trauma to the periocular region can seriously damage ocular structures and their adnexa. The eyelids can be damaged during these traumas. The most frequent lesions are lacerations, the surgical treatment of which is generally simple. In some cases, there are complex traumas where there is a loss of tissue, which is difficult to treat. We report the case of a 26-year-old young man, farmer with no medical and surgical history, referred by the odontostomatology and maxillofacial surgery department for burns to the left hemi face by the exhaust pipe of his motorbike which occurred following a public road accident (AVP). Observation: A 26-year-old young man with no medical-surgical history, visual acuity was 5/10 with good mobility of the globe. In collaboration with the maxillofacial surgeon, a graft of the hemi face was performed using a flap from the inner side of the thigh first. In the second time we carried out a recovery by a flap which consisted in taking a supra-superciliary flap and suturing it at the level of the palpebral edges which, in spite of a fragile vitality of the tissues. Conclusion: The reconstruction of the eyelid is a real problem in our service because of the technical platform and the availability of consumables, which limits us in the choice of the operating technique.

Effects of aging on the evolution of Apical Periodontitis lesions in rats

This study aimed to evaluate the effects of aging on the evolution of Apical Periodontitis (AP) lesions in rats. Elderly males (study group, n = 12) and young males (control group, n = 12) Wistar rats were used. When the study group were 24 months old and the control group were 3 months old, AP lesions were induced by creating pulp exposure of the mandibular left first molars. After 21 and 40 days, the animals were euthanized and the mandibles were removed. The left hemi- mandibles were radiographed and the AP lesions of the mesial roots of the first molars were measured using ImageJ software (National Institute of Mental Health, Bethesda, USA). The AP lesions were significantly larger in the Elderly (E) group (p = 0.0006) compared to the Control (C) group (E 21: 218.8 ± 72.96, C 21: 94.77 ± 9.44, E 40: 237.8 ± 57.20, C 40: 85.23 ± 6.63). The lesions of the animals in the elderly groups were significantly larger than the lesions in the younger animals. These findings suggest that the bone and immunological changes caused by aging can influence the progression of AP lesions.

A case of Artery of Percheron infarct caused by Dengue virus encephalitis

In this communication, we describe a patient with dengue virus encephalitis who presented with fever and sudden onset bilateral oculomotor nerve involvement with left side hemi paresis, MRI showing bilateral thalamus and midbrain involvement (artery of Percheron infarct).

A death due to complications following late-onset congenital diaphragmatic hernia in a young child

Congenital diaphragmatic hernia (CDH) is a rare anatomical birth defect, causing the diaphragm fails to fuse completely, leaving a defect and causing herniation of the abdominal viscera towards the thoracic cavity. Though most cases of CDH are symptomatic and diagnosed in the early stages of life some asymptomatic cases may go undetected and later detect as incidental or may present with respiratory or gastrointestinal symptoms. We report a case of late-onset CDH which leads to a rapidly fatal medical emergency causing challenges in clinical diagnosis. An eight-year-old previously healthy schoolgirl was admitted to a primary care hospital following recurrent upper abdominal pain, nausea, and vomiting for a duration of 3 consecutive days. According to the parents she has taken treatment from a general practitioner. She was afebrile, hypotensive, tachycardic, and drowsy and was found unresponsive during transfer to a tertiary care hospital and was pronounced dead. On opening the thoracic cavity, it was noted that some of the abdominal contents like the entire stomach, duodenum, and proximal part of the small intestine, splenic flexure of the transverse colon were present within the left hemi thorax causing left lung hypoplasia, thoracic midline shift, intestinal compression, and elevated luminal pressure causing gastric erosions and chemical peritonitis. This case highlights the importance of higher clinical vigilance and the value of early diagnosis and timely medical attention to relatively uncommon but surgically correctable conditions like CDH.

Large emphysematous bulla after COVID 19 pneumonia

A 38-year-old man, with history of COVID 19 pneumonia 23 days back, non-smoker and known case of hypertension presented to the emergency department with complain of sudden onset multiple episodes of blood mixed sputum associated with shortness of breath and sharp type of left sided chest pain for last five hours. The patient was dyspneic, tachypneic and hypoxemic at the time of examination with SPO2 of 84 to 86% without oxygen which improved to 95-96% after 15 liter/min of oxygen via high flow nasal cannula. There were no breath sounds in left hemi thorax and decreased breath sound on right side with basal crepitation. Chest radiograph revealed left sided pneumothorax, needle decompression done immediately followed by chest tube insertion and maintaining 95-96% oxygen at 8 l/m after the procedure. The patient was admitted, and HRCT revealed giant emphysematous bulla in posteromedial aspects of left lobe. This is to highlight the complications that were observed in post COVID patient.

Free Fibula Flap in Mandibular Reconstruction : A Case Report

The reconstruction of the mandible is a complex procedure and continues to be a challenge in reconstructive maxillofacial surgery. Indications for mandibular reconstruction are varied and include pathological resections, traumatic injuries and residual deformities amongst others. The mandible is an important anatomical unit of maxillofacial skeleton in terms of both aesthetics and function which necessitates its immediate reconstruction after resection.
 A 16 years old female patient, diagnosed with ameloblastoma of left hemi -mandible underwent resection with immediate reconstruction using free fibula flap. Twenty two months follow up reveals excellent bony union and facial contours. The objective of the treatment is to resecting the mandibular defects and reconstruction with free fibular flap.
 Our experience combined with positive literature references enhances the reliability of free fibular vascularized graft as a suitable and versatile reconstructive option for complex anatomical contours of the mandible.

A CASE OF FOVILLE SYNDROME

60 year old diabetic and hypertensive female presented to casualty with right hemiplegia and hemianesthesia with lower motor neuron type of facial nerve palsy and loss of pain, temperature on left side of the face. She had difculty adduction and abduction on left eye with horizontal nystagmus in the contralateral eye when abducted while vertical movements were preserved. MRI brain was done which showed acute focal non hemorrhagic infarct in the left hemi pons along with partial basilar artery thrombosis. Hence a diagnosis of foville syndrome with inter nuclear opthalmoplegia was made. Classically foville syndrome is characterised by ipsilateral sixth nerve palsy, lower motor neuron facial nerve palsy, fth sensory nuclear palsy along with contralateral hemiparesis and hemisensory loss. The patient was started on single antiplatelet along with high intensity statin. On follow up after 3 months patients power improved.

Congenital Lobar Emphysema in a 17-Day-Old Male Neonate: The Plain Radiographic Features and a Case Report

Congenital lobar emphysema (CLE) is a rare respiratory disorder which allows air to enter the lungs but can’t escape causing over-inflation of the lobes of the lung. This condition (CLE) is commonly detected in the newborn or young infants but some cases are diagnosed in adulthood. Congenital lobar emphysema is a rare congenital malformation with a prevalence of 1 in 20,000 to 1 in 30, 000, and more prevalent in males, with a male to female ratio of about 3:1. This is a 17 day old male neonate that presented with respiratory difficulty and .had a supine chest radiograph that showed an overinflated left lung field more on the upper and middle zones with flattening of the left hemi diaphragm, marked shift of the heart and mediastinum to the right with some degree of loss of volume involving the right lung. We report the radiographic findings of this case due the rare nature of congenital lobar emphysema.

Laparoscopic repair of giant diaphragmatic hernia after minimal invasive esophagectomy: a case report and review of the literature

: The incidence of esophageal cancer (EC) is rapidly increasing, as well as the overall survival of patients affected by it, given the improvement in its multimodal treatment. Minimally invasive esophagectomy (MIE) is the cornerstone to reach this goal, but the alteration of the anatomy that comes along with the surgery leads to an increased risk of diaphragmatic hernia (DH). This latter is a rare but highly morbid complication of MIE, which is expected to become more and more relevant. A 61-year-old man undergone to MIE for cancer, with uneventful immediate post-operative course, presented to our observation, 8 years after the procedure, with unspecific abdominal pain and vomiting. The CT scan showed a giant DH involving the small bowel and the transverse colon, which ascended in the thoracic cavity through a large defect of the left hemi diaphragm. A laparoscopic transabdominal repair, with direct suture of the diaphragm pillars, was performed. We did not record any immediate or long term post-operative complications, but a recurrence at 2 years CT scan follow-up. We treated the recurrent DH with an open repair employing a dual mesh placed on the left hemi diaphragm. No post-operative complications or further recurrences have been recorded. DH may be a life threatening early or long term post-esophagectomy complication. Nowadays, still little is known on its risk factors, and it has a nuanced clinical presentation, which frequently brings to a delayed diagnosis. Moreover, to the best of our knowledge a general consensus is lacking on the most appropriate attitude or technique to adopt in front of this uncommon disease. Our personal experience shows the efficacity and safety of a surgical approach, with direct suture, in a symptomatic post-MIE.