Left Tube Research Articles

Bilateral Chylothorax After Severe Vomiting in a Child

In the etiology of chylothorax, traumas and malignancies are the first two leading causes. Today in pediatric patients, the most common cause of chylothorax includes the complications secondary to cardiothoracic operations. Bilateral chylothorax is rarely observed after severe vomiting leading to increase in intrathoracic pressure. In idiopathic chylothorax, bilateral localization is dominant. A 9-year-old girl who presented to our emergency department with the complaints of dyspnea and back pain following severe vomiting received a diagnosis of bilateral chylothorax. The patient was treated with the insertion of a bilateral chest tube, and pleurodesis was performed in left hemithorax. Examination did not reveal a pathology to this condition, except the vomiting observed 2 days previously after the meal.

Management of Lower Vaginal Agenesis in a Patient With Unicornuate Uterus

Management of Lower Vaginal Agenesis in a Patient With Unicornuate Uterus

Obstruction of Hemivagina Without Ipsilateral Renal Agenesis in Septate Uterus

through procedure at an OSH via a sagittal incision for treatment of the imperforate anus. A small vagina was identified high on the right which was found to be “short” and connected to a “short uterus” with an associated tube and ovary. It was surgically lengthened with flaps from the labia and connected to the introitus. A small fistula going from the vagina to a ureteral remnant from a dysplastic kidney was identified, divided, and ligated. She subsequently did well. Signs of pubertal development were evident at age 10 e 11, with normal breast development and accelerated growth; however, menarche was absent. At age 14, she presented for evaluation of primary amenorrhea and pain. Ultrasound identified two uterine horns, a right ovary, and a distended fluid filled vagina. MRI showed a hematocolpos which appeared contiguous with the right corpus and tube. Left rudimentary uterine corpus and tube were not fluid filler. A re-do vaginoplasty was planned. EUA demonstrated extensive scar tissue with a stricture at 1.5cm from the introitus. Given the history of prior urologic and rectal surgery, and the fact that her unicornuate system was not midline, intra-operative ultrasound was used to identify the inferior aspect of the hematocolpos. With ultrasound guidance a long spinal needle was advanced until it was noted to enter the inferior aspect of the obstructed vagina (Figure 2). Once the angle and direction of dissection was determined, electrocautery was used to carry the dissection upwards. The intervening tissue was excised and 900cc of old blood was evacuated. Vaginal mucosa was identified and a standard pull through vaginalplasty was performed. Vaginal pull through is the standard treatment for lower vaginal agenesis. With a single midline uterus, cervix and upper vagina, the distal aspect of the obstructed upper vagina can be identified by palpation, and

Removal of Hairy Polyp of the Eustachian Tube Using a Novel Skull Base Approach: Extended Transmastoid Excision

Hairy polyps are rare dermoid tumors associated with the temporal bone. The majority of reported cases have been left-sided, in women, and with significant middle ear or nasopharyngeal components, allowing removal by a simple transmastoid or endoscopic approach. We present the case of a 3-year-old girl with a hairy polyp of the left eustachian tube. Diagnosis was made at surgery 14 months after initial presentation. Preoperative CT and MRI aided surgical planning but were nondiagnostic. The location of this lesion high in the eustachian tube and its intimate association with the carotid artery precluded a traditional transcanal, endoscopic, or simple transmastoid approach and required more aggressive surgical dissection. A novel extended transmastoid skull base approach with removal and replacement of the anterior external canal wall and glenoid fossa provided complete visualization of the intrapetrous portion of the carotid artery, which was immediately adjacent and adherent to the tumor, and granted access to the apex of the cartilaginous eustachian tube from which the tumor arose. This exposure allowed for complete excision of the tumor and reconstruction of the ear with the usual features of a canal wall down mastoidectomy. This case represents the 15th such lesion reported in the English literature and the first described extended transmastoid skull base approach for complete visualization of the intrapetrous portion of the carotid artery and access to the cartilaginous eustachian tube.

Bilateral Tension Pneumothoraces Leading to Cardiac Arrest after Coronary Artery Bypass Surgery

Bilateral pneumothoraces are a very rare event. In clinical settings, inadvertent incursion into the pleural space resulting from diagnostic or therapeutic medical interventions such as bilateral venipunctures or damage to the lung parenchyma due to high pressure ventilation may be causative. Bilateral pneumothoraces postcardiac surgery are rarely reported. We present the case of bilateral tension pneumothoraces leading up to cardiorespiratory arrest in a 57-year-old male, weighing 130 kg, who underwent without any complications a coronary artery bypass surgery. Thoracic chest tubes (retrosternal and intrapericardial) and a left pleural tube were removed 24 hours prior to the incident. Diffuse sternal pain sensation accompanied by slow progressive respiratory distress and confusion shortly before the incident were all developed over a period of 12 hours. A prompt cardiopulmonary resuscitation and bilateral chest tube insertion had prevented a fatality in the patient.

The Dilemma of Bilateral Tubal Pregnancy: Case Report and Literature Review

This is a case of a 28-year-old lady, nulliparous lady, with a two year history of primary infertility. She had undergone infertility investigations which revealed an ovulation with low day 21 progesterone assay. Pelvic ultrasound scanning showed a normal uterus and endometrium, bulky left ovary and normal right ovary. Laparoscopy, hysteroscopy and tubal dye test revealed mild to moderate endometriosis, probable chocolate cyst on the left ovary, tortuous and blocked left tube. However, there was a normal and patent right tube. Her husband’s seminal analysis was sub-optimal with a good count of 47 million sperm/ml. However, only 7% normal forms and 4% were with rapid progressive motility. The diagnosis of sub fertility in both partners was made.

Novel rat model of tympanostomy tube otorrhea

Objective Tympanostomy tube otorrhea (TTO), caused by the presence of pathogenic bacteria in the middle ear, is the most common complication of TT insertion. No studies have described a reproducible animal model of TTO. We aimed to develop a rat model of TTO which, in turn, could be used to assay the levels of TNF-α and IL-1β through the course of the infection. Methods The left Eustachian tubes of 55 male Sprague-Dawley albino rats were occluded with gutta-percha (ETO = Eustachian Tube Occlusion). Middle ear (ME) effusion was ascertained by weekly otomicroscopy. At 3 weeks tympanostomy tubes were placed bilaterally and the MEs were inoculated bilaterally with Streptococcus pneumoniae through the tubes. The rats were randomly assigned to one of two daily ototopical treatments: ciprofloxacin/dexamethasone (CDX) or placebo. The animals in each of the two treatment groups were further divided to receive 1, 2, 5 or 7 days of treatment. The rats were sacrificed after treatment was finished. The rates of otorrhea, positive middle ear (ME) cultures, and levels of TNF-α and IL-1β in the ME fluid were measured. Results Left ETO followed by ME inoculation with S. pneumoniae and treatment with placebo resulted in persistent infection (100% culture-positive ME fluid at 10 days) and otorrhea (85.7%). Persistent infection of the left ear was accompanied by significantly elevated the levels of IL-1β and TNF-α. Ears treated with CDX had lower rates of otorrhea at all time points and lower levels of IL-1β and TNF-α. Conclusions This study is the first to describe a reproducible animal model of acute TTO. Surgical obstruction of the ET, followed by TT placement and ME inoculation with S. pneumoniae induced persistent otorrhea and infection. Both IL-1β and TNF-α appear to be potential markers of persistent middle ear infection. This novel model may be used in future studies of the pathogenesis and therapy of TTO.

Tube Extrusion and Cheese Wiring Five Years Post Dacryocystorhinostomy

Objective: Dacrocystorhinostomy (DCR) with silicone tube stenting is a common procedure for congenital nasolacrimal duct obstruction (NLDO). The incidence of congenital NLDO is about 6% in the newborn. The duration the tube is left in place varies depending on surgeon preference. Cheese wiring is one of the tube-related complications when the tube is left behind for a long duration. The term cheese wiring refers to the silicone stent or tubing cutting through soft tissue close to the punctum or canaliculi like wire cuts through cheese. We present a case of tube extrusion with cheese wiring 5 years post DCR.
 Methods:
 Study Design: Case report
 Setting: Tertiary Referral Centre
 Patient: One
 Results: A 16 year old Indian male with congenital bilateral NLDO underwent right and left DCR at ages 9 and 11 respectively. The patient presented with smelly nasal discharge 5 years later to the ENT clinic. On initial examination the right tube was in place but the left tube was not visualized. Nasal endoscopy however revealed that both tubes were still there and were subsequently removed.
 Conclusion: DCR with silicone intubation is a common practice. Early follow up is essential to prevent complications. If tube extrusion is suspected, early endoscopic examination is essential to confirm it
 
 Keywords: nasolacrimal duct obstruction, dacrocystorhinostomy, tube extrusion, cheese wiring

Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery?☆

Flexible bronchoscopy is recommended to confirm correct placement of double-lumen tubes used for thoracic anesthesia. However, there is still controversy over routine bronchoscopic confirmation of their position. This study aimed to verify the usefulness of flexible bronchoscopy for confirming the position of double-lumen tubes after blind intubation. During a 9-month period, consecutive patients undergoing elective oncologic thoracic surgery were prospectively enrolled in the study. All patients were intubated with a left disposable polyvinyl chloride double-lumen tube. Immediately after intubation, clinical verification was made by the anesthesiologist. Then, the endoscopist performed flexible bronchoscopy with a 2.8-mm diameter Olympus(®) video bronchoscope, and verified the position of the double-lumen tube, before positioning the patient. The double-lumen tube was in optimal position, if the bronchial cuff was immediately below the tracheal carina, and there was a clear view of the left subcarina, with unobstructed left upper and lower bronchi. Misplacement of the double-lumen tube was diagnosed when the tube had to be moved (in or out) for more than 0.5 cm to correct its position. Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi, requiring immediate re-intubation under bronchoscopic guidance. A total of 144 patients (44 women (42%) and 60 men (58%), with a mean age of 51 years (range 25-77 years)) were enrolled in the study. Surgical procedures included 37 right-sided and 31 left-sided thoracotomies, 22 video-assisted thoracoscopic surgeries (VATSs) (16 right-sided and six left-sided), one median sternotomy, six mediastinotomies, and seven miscellaneous procedures. In 66 (63%, 95% confidence interval 53.2-71.8%) cases, there was complete agreement between the anesthesiologist and the endoscopist. The latter diagnosed misplacement of the double-lumen tube in 33 (32%, 95% confidence interval 22.8-40.7%) patients and critical malposition in five (5%, 95% confidence interval 0.7-8.9%) cases. After blind intubation, 37% of double-lumen tubes required repositioning by means of flexible bronchoscopy, despite positive evaluation made by the anesthesiologist. Our data suggests that initial bronchoscopic assessment should be made with the patient still in the supine position, and confirms that flexible bronchoscopy is useful in verifying the correct position of double-lumen tubes or adjusting possible misplacements, before starting thoracic surgery.

P34.12: The use of laparoscopic ultrasound in an unusual case of bilateral ectopic pregnancies: a case report

The patient was a 33 years old lady with secondary infertility. She was referred to our unit for left tubal ectopic pregnancy at six weeks of gestation. The pregnancy was conceived by ovulation induction and intrauterine insemination. She complained of small amount of vaginal bleeding. There was no abdominal pain. Clinical examination was unremarkable. Transvaginal ultrasound showed thickened endometrium. The ovaries were multicystic and enlarged, which was compatible with the history of ovarian stimulation. There was a gestational sac with fetal pole measuring 2.6 mm at the left adnexa. The diagnosis was left tubal ectopic pregnancy and the patient was counseled for laparoscopic left salpingectomy. During the operation, however, both fallopian tubes were found swollen. There was difficulty in deciding the site of the actual ectopic pregnancy and hence, the side requiring salpingectomy. Laparoscopic ultrasound has been used in our unit for detecting pelvic nodal metastasis in cervical carcinoma. The laparoscopic ultrasound probe is a multi-frequency (5.0-, 6.5-, and 7.5-MHz) probe measuring 10 mm in diameter. (Panther Ultrasound Scanner System, B&K, Denmark). Between 0.5 L and 1 L of normal saline is required to provide an acoustic window for the ultrasonography. In order to proceed with appropriate surgical treatment, we performed laparoscopic ultrasound along the bilateral swollen fallopian tubes. Scanning of the left tube showed the presence of a gestational sac with a fetal pole measuring 3.9 mm with pulsation. Unexpectedly, there was a gestational sac measuring 1.5cm in the right tube. Therefore, laparoscopic left salpingectomy and right salpingotomy were performed. Pathological examination confirmed the left tubal ectopic pregnancy and the presence of products of gestation from the right tube. Our case demonstrated the potential role of laparoscopic ultrasound in delineating the location of the ectopic pregnancy in situations with equivocal clinical findings.

Heterotopic triplet pregnancy: report of a patient with remnant tubal ectopic and intrauterine twin pregnancy after frozen‐thawed embryo transfer

A case of heterotopic triplet pregnancy after frozen-thawed embryo transfer is presented. The patient conceived after transfer of three frozen-thawed embryos at a fertility clinic where she had previously undergone laparoscopic left salpingectomy due to pyosalpinx. Approximately 4 weeks after the embryo transfer, she presented with a complaint of abnormal genital bleeding and was diagnosed by ultrasound as having a dichorionic twin pregnancy. One week later, she was referred to our hospital because of lower abdominal pain. Hematoperitoneum was suspected based on findings of low blood pressure and tachycardia. Diagnostic emergent laparoscopy demonstrated an ectopic pregnancy in the remnant isthmic portion of the left tube. Laparoscopic excision of the remnant fallopian tube was performed, but the procedure resulted in early-pregnancy loss of one of the twins. The risk of heterotopic pregnancy is not small under assisted reproductive technology. Attention should be paid to the risk of tubal pregnancy after transferring more than two embryos or controlled ovarian hyperstimulation, even after salpingectomy has been performed.

Rupture of a rudimentary horn at 16 weeks of gestation

A patient with acute abdomen at 16th week of gestation underwent an emergency laparotomy. At laparotomy two litres of fibrinated and free blood and a dead fetus with placenta was detected intraabdominally. The right ovary and tube was normal and the uterus was normal in size. There was a ruptured and actively bleeding uterine horn on the left side of the uterus. The ruptured uterine horn was excised with the left tube by preserving the left ovary. The patient recovered without any complications

Borderline papillary serous tumor of the fimbriated end of the fallopian tube with peritoneal implants

Diagnosis of Borderline papillary serous tumor of the fallopian tube was comprehensively established by Zheng in 1996 supported mostly by a histological similarity to its ovarian counterpart. It is a very rare entity with eight cases published so far and the ninth case described here as a 41-year-old woman presented with non-specific lower abdominal pain, dyspareunia and dysuria. Left adnexal mass was identified and she was operated on. It turned out the tumor was attached exclusively to the left tube, with no connection to any of the surrounding structures and with histology of borderline serous tumor with non-invasive implants in the left and right ovary and visceral peritoneum. Reviewing available data on genetics of these tumors there was diploid status in one examined tumor, and in our case no mutations of KRAS, BRAF and p53 genes were found. Histomorphology remains the mainstay of diagnosis and staging operation is the mainstay of patient management. Prognosis is uncertain with a 6-year survival documented in one case.

Successful Endovascular Repair of Two Ruptured Thoracic Aortic Aneurysms in Nonagenarians

Ruptured thoracic aortic aneurysm (rTAA) is a catastrophic and mortal event. Thoracic endoVascular aortic repair (TEVAR) has emerged as an alternative to open repair. We report the first two successful TEVAR performed for rTAA in nonagenarians. Patient 1 was a 92-year-old man with multiple comorbidities with a 5.6 cm thoracic aortic aneurysm who was admitted for anticoagulation for pulmonary embolism. Twelve hours later, he was found to be hypotensive and the X-ray showed an opacified left hemithorax (Fig. 1). A 40 mm × 20 cm Gore TAG stent-graft (W. L. Gore & Associates, Inc., Flagstaff, AZ) was deployed to successfully exclude the rupture. The postoperative course was uncomplicated and on day 9, he was discharged to a skilled nursing facility. Patient 2 was a 94-year-old man with a history of multiple comorbidites and endovascular aneurysm repair for ruptured abdominal aortic aneurysm 3 years earlier, who presented to the emergency room in hemorrhagic shock. Computed tomography scan revealed hemomediastinum and left hemothorax suggesting thoracic aorta rupture (Fig. 2A). Emergently, a 34 mm × 30 cm Gore TAG stent-graft was deployed (Fig. 2B). A left chest tube was placed. Postoperative course was briefly complicated by acute renal failure and pneumonia and on day 14, he was discharged to a rehabilitation center. TEVAR for rTAA is an effective option and advanced age alone should not deter definitive repair of the thoracic aorta.

Transbronchial Occlusion of a Malignant Bronchopleural Fistula With Cyanoacrylate Glue

A 73-year-old man who had undergone surgery for lingual cancer, followed by radiation therapy and chemotherapy, presented with severe dyspnea. A chest radiograph revealed a left tension pneumothorax. An immediate tube thoracostomy alleviated his dyspnea. A chest computed tomography scan showed multiple large cystic tumors in both lungs. Squamous cell carcinoma was cytologically proven in the pleural effusion. A malignant bronchopleural fistula due to a metastatic pulmonary tumor was diagnosed. Surgical interventions were tried twice. However, air leakage occurred when the rapidly recurring tumor caused bilateral pneumothoraces. Thus, bronchoscopic closure was conducted. A flexible video bronchoscope and a thin catheter were inserted into the targeted left bronchiolus. The lumen of the catheter was filled with water. Cyanoacrylate glue and lipiodol were mixed in 2 syringes, and the mixture was slowly injected and then flushed with water. As soon as the lipiodol accumulation was visualized by radiograph fluoroscopy, the air leakage stopped. Pleurodesis with the intrathoracic administration of OK-432 was added to both pleural cavities, and the left and right chest tubes were removed on the third and fifth days, respectively. The patient was discharged the following day. However, he died of the disease a month later.

Letters to Editor A of bilateral tubal ectopic pregnancy following day 5 embryo transfer

Letters to Editor A of bilateral tubal ectopic pregnancy following day 5 embryo transfer

Intra-ligamentous fibroid removed laparoscopically

In this paper, we report the case of a left round ligament fibroid in a 24 year-old, gravida 0, female that was successfully managed laparoscopically. Operative findings also included severe adnexal adhesions bilaterally, severe adhesions of the liver to the anterior abdominal wall (Fitz-Hugh-Curtis syndrome), pigmented areas on the left tube, uterus and posterior broad ligament (that proved to be endometriosis), and low capacity bladder (450 cc at 70 cm water pressure) with florid glomerulations and Hunner’s ulcers consistent with typical interstitial cystitis. Beside the feasibility of laparoscopic management of intra-ligamentous tumors this case highlights the common multifactorial nature of chronic pelvic pain and the frequent association of endometriosis and interstitial cystitis.

Ectopic pregnancy after assisted reproductive technology: a retrospective study

In this study from 2006 to 2010,1628 IVF-ET cycles were performed in our unit. Long protocol with GnRH agonist plus recombinant FSH, short protocol with GnRH antagonist, short protocol with microdoses of GnRH agonist (flare up), natural modified cycle with GnRH antagonist and hCG were applied. The serum level of the P-hCG was measured 12 days after embryotransfer (ET). When positive, the P-hCG level was determined every 4 days until the ultrasound examination 22 days after the ET. From 1628 IVF - ET cycles, we had 10 tubal pregnancies (0,61%) and one heterotopic pregnancy (HP). Salpingectomy was performed in all patients, 7 had laparoscopy, and 3 underwent emergent laparotomy due to hemorrhagic shock. Regarding the HP patient, an ultrasound scan confirmed a viable intrauterine 8-weeks gestation and an ectopic pregnancy (EP) in the left tube with fetal heartbeat corresponding to gestational age of 7-8 weeks. Laparoscopy with left salpingectomy was performed the following day. The intrauterine pregnancy proceeded uneventfully. The patient delivered by elective Cesarean section at 39 weeks of gestation due to breech presentation. Patients undergoing IVF-ET must be informed of the risk of EP and the possibility of HP should not be ignored.

Facilitating tracheal intubation in pediatric patients with the Airtraq® optical laryngoscope

To the Editor, The Airtraq optical laryngoscope (Airtraq) (Prodol Meditec S.A., Vizcaya, Spain) is a relatively new disposable tracheal intubation device with an anatomically shaped blade that has two parallel channels, the optical channel and the guiding channel, which accommodates the endotracheal tube (ETT). The Airtraq incorporates a guiding channel to the right of the viewing axis to solve the challenge of passing the ETT through the glottis. However, delivering the ETT through the gap between the end of the guiding channel tube to the glottis may not be straightforward. The guiding channel tube and viewing axis are somewhat incongruent, because the direction of ETT advancement from the guiding channel is defined by the configuration of the guiding channel tube and the ETT angulation. When attempting to advance the ETT through the laryngeal aperture with the Airtraq during tracheal intubation, it has been reported that a posterior tube tip location can be problematic, especially for pediatric patients. On the basis of our cumulated experience with the Airtraq, which includes more than 500 pediatric patients to date, another possible difficulty in advancing the ETT through the glottis, especially in infants and young children with smaller airways, is a left tube tip location. This potential problem arises because the Airtraq is designed with the guiding channel at the right of the viewing axis, and a left-oriented slope at the right side of the distal opening of the guiding channel is devised to direct the tube tip into the glottis in the midline (Figure, Panel A). This design results in ETT advancement from the guiding channel towards the left. Consequently, during advancement of the ETT, the tube tip may move across the midline (Figure, Panel B) towards either the left vocal cord or the left laryngeal vestibule rather than align the ETT towards the midline of the glottis (Figure, Panel C). Whenever this problem arises, our practice has been to withdraw the ETT by approximately 0.5 cm and to exercise one of four available options: 1) slightly rotate the Airtraq in a clockwise direction; 2) advance the Airtraq downwards; 3) gently apply leftwards laryngeal pressure with external laryngeal manipulation, then re-attempt ETT advancement; and 4) in the very rare occasions the above measures fail, withdraw the ETT from the guiding channel and introduce a pediatric bougie into the visualized glottis via the guiding channel. The ETT is then railroaded along the bougie through the larynx, and the Airtraq is used to monitor the progress of the ETT advancement. Over the previous two years, we have used these maneuvers quite successfully to facilitate advancing the ETT into the glottis with the Airtraq device in pediatric patients with uncomplicated and difficult airways alike.

Laparoscopic management of primary abdominal pregnancy: a case report

This is a case report of a primary abdominal pregnancy managed by laparoscopic intervention. A 22 year old, gravida 1, woman was admitted to our emergency room with vaginal bleeding and pain in lower abdomen. She was 4 weeks pregnant according to her last menstrual period. She had undergone right salpingoophorectomy previously. Pelvic examination revealed cervical motion tenderness, bilateral adnexal tenderness and rebound tenderness. Her vital signs were normal. Beta hCG was 15826 IU/ml and hemoglobin was 10.0 g/dl. Transvaginal sonography showed an endometrium of 3 mm thickness and free fluid in the pelvis. Upon admission to the Early Pregnancy Clinic, abdominal pain became worse and hemoglobin decreased to 8.0 g/dL. Therefore, we performed a laparoscopy which showed that the uterus, left tube and ovary were completely normal with absence of the right ovary and tube. Approximately 500 cc blood was aspirated from the pelvis. Between the right sacrouterine ligament and rectum, there was a bleeding area 2 cm in width which was removed with forceps and sent for frozen pathological examination,which revealed 'placental tissue fragments'. Endometrial sampling was reported to be 'secretory endometrium'. A rapid decrease in the beta HCG post operative titer confirmed the resolution of the pregnancy. Primary abdominal pregnancy is extremely rare. The diagnosis is confirmed according to Studdiford's criteria. In the literature, there only a few cases of abdominal pregnancy in which laparoscopic procedure has been used effectively as treatment. However, laparoscopic procedure is usually successful in treatment of abdominal pregnancy if the gestational age is early enough.