Resection Of Stenosis Research Articles

Mechanical Aortic Valve Replacement in Children and Adolescents After Previous Repair of Congenital Heart Disease

Due to improved outcome after surgery for congenital heart defects, children, adolescents, and grown-ups with congenital heart defects become an increasing population. In order to evaluate operative risk and early outcome after mechanical aortic valve replacement (AVR) in this population, we reviewed patients who underwent previous repair of congenital heart defects. Between July 2002 and November 2008, 15 (10 male and 5 female) consecutive patients (mean age 14.5 +/- 10.5 years) underwent mechanical AVR. Hemodynamic indications for AVR were aortic stenosis in four (27%), aortic insufficiency in eight (53%), and mixed disease in three (20%) after previous repair of congenital heart defects. All patients had undergone one or more previous cardiovascular operations due to any congenital heart disease. Concomitant cardiac procedures were performed in all of them. In addition to AVR, in two patients, a mitral valve exchange was performed. One patient received a right ventricle-pulmonary artery conduit replacement as concomitant procedure. The mean size of implanted valves was 23 mm (range 17-29 mm). There were neither early deaths nor late mortality until December 2008. Reoperations were necessary in five (33%) and included implantation of a permanent pacemaker due to complete atrioventricular block in two (15%), mitral valve replacement with a mechanical prosthesis due to moderate to severe mitral regurgitation in one (7%), aortocoronary bypass grafting due to stenosis of a coronary artery in one (7%), and in one (7%), a redo subaortic stenosis resection was performed because of a secondary subaortic stenosis. At the latest clinical evaluation, all patients were in good clinical condition without a pathological increased gradient across the aortic valve prosthesis or paravalvular leakage in echocardiography. Mechanical AVR has excellent results in patients after previous repair of congenital heart defects in childhood, even in combination with complex concomitant procedures. Previous operations do not significantly affect postoperative outcome.

Abstract No. 8: Clinical Significance of Post Renal Transplant Ureteritis Following Treatment with Multi-Purpose Biliary Drainage Catheters

A mainstay of percutaneous treatment of urological complications following kidney transplantation is drainage via multi-purpose biliary catheters. The effect of the large side-bores on these catheters on the adjacent ureter is not well understood or described. This study retrospectively evaluates the hypothesis that the presence of internal biliary drains correlates with the secondary radiographic appearance of ureteritis. Further, the study attempts to assess the clinical significance of this finding. Ureterograms performed on post renal transplant referrals for percutaneous nephrostomy (PCN) were retrospectively analyzed for 1) ureteral appearance, 2) position/type of prior PCN drainage, and 3) corresponding plasma creatinine (Cr). Patients were excluded for: 1) incomplete follow-up, 2) referrals after surgical revision of the ureteral anastamosis, and 3) underlying lymphoproliferative disorders. Patients were categorized: Group 1 (internal-external drain only), Group 2 (external only), Group 3 (internal-external drain followed by subsequent external drainage), and Group 4 (external drain followed by subsequent internal-external drain). Assessment of ureterograms for changes in ureteral appearance was correlated with Cr to quantify the clinical significance. From April 2000 to June 2007, 1619 renal transplants were performed. Thirty-four of 44 referrals for PCN met inclusion and exclusion criteria. Ureteral irregularity (n=15) occurred either after internal-external drain placement or after conversion from external to internal-external drain in 14 patients (93%). Eight of 15 (53%) patients had persistent ureteritis until conclusion of treatment; 7 of 8 had eventual nephrectomy or stricture resection. Seven of 15 (47%) patients had spontaneous resolution of the finding on subsequent imaging. Diffuse ureteral irregularity may accompany refractory strictures; this finding may also reflect a benign inflammatory process. Presence of this finding is associated with prior internal-external biliary catheters. Our study suggests further investigation into transplant-specific drainage catheters to differentiate benign processes from those requiring definitive treatment.

Anastomotic dilatation after repair of esophageal atresia with distal fistula. Comparison of results after routine versus selective dilatation

After repair of esophageal atresia with distal fistula (EADF), anastomotic dilatations are often required. We abandoned routine dilatations (RD), in 2002, for selective dilatations (SD) only when the symptoms arose. We compared the number of dilatations and long-term results after RD and SD. Eighty-one successive EADF patients from 1989 to 2007 (RD 46, SD 35), with primary anastomosis, native esophagus, and peroral feeding, were included. Spitz classification, birth weight, gestational age, incidence of gastroesphageal reflux, tracheomalacia, and postoperative complications did not differ statistically significantly between the groups whereas the total incidence of associated anomalies in RD group was higher than in SD (P < 0.05) In RD group, anastomotic dilatations were begun 3 weeks postoperatively and repeated until the anastomotic diameter was 10 mm. In SD group, dilatations were performed only in symptomatic patients. The number of dilatations, dilatation-related complications, nutritional status, and outcome up to 3 years after repair were compared. The median number of dilatations was seven (2-23) in RD and two (0-16) in SD group (P < 0.01). Sixteen (46%) patients in SD group had no dilatations during the first 6 months. The incidence of dysphagia, bolus obstructions, and development of nutritional status were similar between the groups. The incidence of complications/dilatation was 0.6% in RD and 1.0% in SD group. One patient in RD group underwent resection for a recalcitrant anastomotic stricture. After repair, EADF policy of SD resulted in significantly less dilatations than RD with equal long-term results.

Current Strategy of Repair of Tetralogy of Fallot in Children and Adults: Emphasis on a New Technique to Create a Monocusp‐Patch for Reconstruction of the Right Ventricular Outflow Tract

In older children (>four years) and adults the strategy of repair of tetralogy of Fallot (TOF) should have a low rate of transannular patch to avoid pulmonary insufficiency (PI), and in addition, we developed a new method of reconstruction of the right ventricular outflow tract (RVOT) to reduce PI. From 2001 through 2005, 74 patients (50 male, 24 female; mean age of 13.6 +/- 0.8 years, ranging from four to 34 years) with TOF (67) or double outlet RV (DORV)-type-TOF (seven) underwent complete repair. The resection of RVOT stenosis +/- pulmonary valvotomy was principally through RA. A new two-patch technique to create a folded mono-cusp valve by using autologous pericardium was applied since August 2004. The repair was through RA in 52 patients and through RA + RVOT/PA in 22 patients (18/4). TAPR was performed in 17 patients (23%, eight non-valved and nine valved). The aortic cross-clamp time was 130.1 +/- 6.8 min in TAPR group and 85.8 +/- 4.6 min in non-TAPR group (p < 0.0001). The operative mortality was 4.0% (3/74) in all and 2.9% (2/67) in TOF patients (due to low output, uncontrollable bleeding, and repeated bleeding from the pulmonary collateral vessels late) and was similar in TAPR or non-TAPR. The valved patch-repaired patients had mild PI and good RV function postoperatively up to eight to 12 months. Repair of TOF in older children/adults should include low rate of TAPR of RVOT. If indicated, the new folded monocusp-patch technique is recommended. It is an effective and simple way to markedly reduce postoperative PI with no additional cost.

Laryngotracheal canal for hypopharyngoesophageal stricture after corrosive injury

Aim To evaluate the application of the laryngotracheal canal on the reconstruction of the hypopharyngoesophageal defect resulting from resection of stricture with corrosive injury. Method Ten patients with the hypopharyngoesophageal stricture after corrosive injury due to ingestion of strong alkali in two cases and strong acid in eight treated surgically from January 2005 to December 2007 were studied. Lipiodol esophagography revealed almost complete obliteration of both sides of sinus piriformis in seven patients and stricture of the lower hypopharynx in two cases, and laryngofiberscopy revealed injury of vocal cord in one case. All patients received the operation of the laryngotracheal canal. As an isoperistaltic conduit in eight and an antiperistaltic in two, the colon was placed retrosternally anastomosed with lower margin of larynx for esophageal substitution. Result All patients healed well. No anastomotic leakage was observed. Normal deglutition and weight gain were achieved in all the patients. Postoperative follow-up endoscopy showed no stricture recurrence of anastomosis. Functional results of nine patients (90%) were categorized as good result; only one (10%) faired. Conclusion The application of the laryngotracheal canal therefore can be advocated as the method for reconstruction of the hypopharyngoesophageal defect after resection of stricture due to corrosive injury.

S182 – A Modified Collar for Post-Tracheal Resection Immobilization

Objectives 1) Determine the possible use of a modified cervical collar as an effective immobilization technique post tracheal resection. 2) Demonstrate the use of this alternate technique in clinical practice. Methods 2 patients requiring tracheal resection for tracheal stenosis were identified as having been placed in an Aspen cervical collar brace with modification in the postoperative period to keep the patient's neck immobilized and flexed. Cervical collar braces usually keep a patient's neck in constant extension, but with our modifications, we keep the neck in constant flexion. This method was used in lieu of the traditional ‘chin stitch’ to relieve tension on the tracheal anastamosis in the immediate postoperative period. Patients were assessed during the inpatient postoperative period for comfort level, pain, and mobility in the collar. Patients were followed up as outpatients to evaluate tracheal patency. Results Both patients utilized the cervical collar for the duration of their inpatient stay. One patient had some complaints of difficulty breathing and increased anxiety due to the collar. Overall, both patients found the collar tolerable and denied any pain due to the collar. Patients were followed after discharge from the hospital in the outpatient clinic, and neither patient had evidence of restenosis at 2-month follow-up. Conclusions Though more research needs to be conducted, this approach represents a possibly more comfortable, yet still effective, method of tracheal immobilization status post-resection as compared to the traditional ‘chin stitch.’

High-Frequency jet ventilaton during resection of tracheal stenosis in a 14-year-old case

Pediatric AnesthesiaVolume 18, Issue 8 p. 795-796 High-Frequency jet ventilaton during resection of tracheal stenosis in a 14-year-old case Ali Alagöz, Ali Alagöz Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorFatma Ulus, Fatma Ulus Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorHilal Sazak, Hilal Sazak Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorAkif ÇAmdal, Akif ÇAmdal Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorEser ŞAvkilioğlu, Eser ŞAvkilioğlu Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this author Ali Alagöz, Ali Alagöz Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorFatma Ulus, Fatma Ulus Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorHilal Sazak, Hilal Sazak Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorAkif ÇAmdal, Akif ÇAmdal Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this authorEser ŞAvkilioğlu, Eser ŞAvkilioğlu Department of Anesthesiology and Reanimation, Atatürk Chest Disease and Thoracic Surgery Education and Research Hospital, Ankara, Turkey (email: hilalgun@yahoo.com)Search for more papers by this author First published: 08 July 2008 https://doi.org/10.1111/j.1460-9592.2008.02546.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume18, Issue8August 2008Pages 795-796 RelatedInformation

122 Magnetization Transfer MRI Quantitatively Detects Intestinal Fibrosis in Ex Vivo Human Intestinal Tissue in Crohn's Disease

The natural history of Crohn's disease (CD) involves chronic intestinal inflammation leading to fibrosis and stricture formation. Inflammation is readily identified, but no noninvasive method of identifying fibrosis exists. We previously demonstrated that magnetization transfer MRI (mtMRI), a specialized MRI sequence that detects tissue stiffness, quantitatively detects intestinal fibrosis in an animal model of CD. We hypothesize that mtMRI can quantitatively detect fibrosis in intestinal tissue in human CD. METHODS: Patients with CD scheduled for surgical resection of intestinal strictures were identified. Samples of resected intestinal tissue were obtained from the thickest portion of the stricture, and from the least involved tissue margin. Ex vivo tissue was scanned in Varian Inova 2.0 T, 31 cm clear bore system with Acustar S-180 actively shielded gradients at 10 kHz (Msat) and 100 kHz (M0) offresonance. MT ratio (MTR) of bowel wall was calculated as 100*(1-Msat/ M0). Tissue was sectioned and stained with Mason's trichrome stain and scored for fibrosis by two GI pathologists. The area of collagen per tissue length was determined on trichrome stained sections by image analysis using MatLab. RESULTS: 12 samples of intestinal tissue were obtained from 6 patients with CD undergoing intestinal resection. Mean MTR was 15.6 ± 0.9. The mean histologic fibrosis score was 2.8 ± 0.3. MTR and fibrosis scores did not differ significantly between tissue from mid-stricture and margin. MTR correlated extremely well with tissue fibrosis score (R2=0.75; p=0.006) and with MatLab collagen quantification (R2= 0.58; p=0.04). The histologic fibrosis score correlated well with the Matlab collagen quantification (R2=0.71; p=0.01). CONCLUSION:Magnetization transfer MRI is sensitive to tissue fibrosis in human CD ex vivo tissue and correlates with histologic assessment of fibrosis, and with collagen quantification by image analysis. This is consistent with our findings in an animal model of intestinal fibrosis, and supports our hypothesis that mtMRI can be used to quantitatively detect intestinal fibrosis and could be a useful tool for monitoring the natural history of CD.

Role of Sialoscopy in the Treatment of Stensen's Duct Strictures

The origin of strictures of Stensen's duct often remains unclear, but chronic recurrent parotitis may be one associated disease. Failure of conservative therapy leads to a recommendation of parotidectomy in a high percentage of cases. Nowadays, development of new, minimally invasive methods may lead to a fundamental change in the treatment regimen. We retrospectively evaluated 39 patients who presented with symptomatic strictures of Stensen's duct from 2002 to 2005. Sialoscopy was performed with semirigid endoscopes. Therapy consisted of irrigation and intraductal infusion of cortisone. If possible, interventional sialoscopy was carried out as the first-line procedure. If indicated, operative procedures of the duct were performed. After irrigation and intraductal medication, 17.9% of the patients were free of symptoms. Interventional sialoscopy was carried out in 74.4%, with a success rate of 75.9%. Operative duct procedures (extended papillotomy or resection of papilla stricture with duct reinsertion) were carried out in 23% of cases. In 5.1% of the total cases, parotidectomy was unavoidable. Sialoscopy-based methods play a central role in gland-preserving treatment of strictures of Stensen's duct. Sialoscopy has proven to be a fast, useful, and relatively safe therapeutic tool with a high success rate. Parotidectomy is the last choice in symptomatic cases.

Long-term results of laryngotracheal resection for benign stenosis☆

We report the long-term results of our 16-year experience with laryngotracheal resection for benign stenosis. Between 1991 and 2006, 35 consecutive patients (19 males, 16 females) underwent laryngotracheal resection for subglottic postintubation (32) or idiopathic (3) stenosis. Mean age was 43 years (range 14-71). At the time of surgery 13 patients presented with tracheostomy and 7 with a Dumon stent. The upper limit of the stenosis was from 0.6 to 1.5 cm below the vocal cords. The length of airway resection ranged between 1.5 and 6 cm. Suprahyoid release was performed in two patients and pericardial release in one. Nine patients had psychiatric and/or neurological post-coma disorders. Mean follow-up is over 5 years (61 months; range 3-194). There was no perioperative mortality. Thirty patients (85.7%) had excellent or good anatomic and functional results. Four patients (11.4%) presented restenosis at a distance of 25-110 days from the operation. Restenosis was successfully treated by endoscopic procedures in all four patients. One patient (2.9%) presented anastomotic dehiscence that required temporary tracheostomy closed after 1 year with no sequelae. Three patients (8.4%) had wound infection. Long-term follow-up was uneventful also in patients who had early complications. Long-term follow-up confirms that laryngotracheal resection is the definitive curative treatment for benign subglottic stenosis. Surgical complications can be successfully managed by non-operative procedures. Despite the occurrence of early complications, excellent and stable results can still be obtained at long term.

Single-staged laryngotracheal resection and reconstruction for benign strictures in adults

Laryngotracheal stenosis (LTS) is a challenging problem, and its management is complex. This study evaluated both short- and long-term outcomes following laryngotracheal resection and anastomosis. Between 1994 and 2006, 37 patients underwent surgery for LTS. The cause of stenosis was post-intubation or post-tracheostomy injury in 28 cases and idiopathic in nine. Pearson's technique was used for anterolateral cricotracheal resection (n=23), and Grillo's technique of providing a posterior membranous tracheal flap was used in cases of circumferential stenosis (n=14). Since 1998, we have modified the techniques in 21 cases, using a continuous 4/0 polydioxanone suture for the posterior part of the anastomosis. No peri-operative mortality was recorded. Three (8.1%) patients developed major complications (two fistulae and one early stenosis) that required a second surgical look. We had 16 minor complications in 14 (37.8%) patients. The long-term results were excellent to satisfactory in 36 patients (97.3%) and unsatisfactory in one (2.7%). Single-staged laryngotracheal resection is a demanding operation, but can be performed successfully with acceptable morbidity in specialized centers. The continuous suture in the posterior part of the anastomosis simplifies the procedure without causing technique-related complications. In our experience, this procedure guaranteed excellent to satisfactory results in more than 90% of patients.

Nódulo de pulmão, estenose traqueal e doença coronariana: como abordar quando associadas?

A 67-year-old male patient underwent exploratory thoracotomy for pulmonary nodule resection. The patient presented a cardiorespiratory arrest during anesthesia due to myocardium infarction. After reanimation the patient was referred to ICU where he remained intubated for 7 days. Subsequently, he developed cervical tracheal stenosis. At first, the patient underwent a myocardium revascularization followed by surgical resection of tracheal stenosis through tracheoplasty.

Surgical Treatment of Long-Segment Tracheal Anomalies in Infants and Children

Tracheal stenosis in combination with vascular and/or cardiac anomalies is a life-threatening condition in infants and children presenting with severe symptoms of airway obstruction. The optimal surgical treatment of these cases remains controversial. We present here a group of infants and children with combined tracheal malformations and vascular and/or cardiac anomalies. More than 30 % of the stenotic trachea was resected in a subgroup of the patients. A reconstruction with end-to-end anastomosis was achieved on the basis of extensive mobilization of the whole tracheobronchial tree and use of CPB. The clinical outcome in 37 children with a median age of 8 (1 - 72) months was analyzed retrospectively. The patients presented with severe airway obstruction in combination with congenital heart defects and/or vascular anomalies. Cardiac catheterization, bronchoscopy and thoracic computer tomography were performed prior to operation. The operations were performed under CPB and consisted of tracheal resection with end-to-end anastomosis or external stabilization. Associated intracardiac and vascular anomalies were repaired simultaneously. All but 1 patient survived and had a straightforward recovery. The patients were extubated under bronchoscopic control with a median intubation time after airway repair of 12.2 days. The average follow-up was 8.4 years (1 - 14 years) and the surviving patients did not show signs of restenosis clinically. A segment longer than 30 % of the tracheal length was resected and reconstructed with end-to-end anastomosis in 57 % of the patients (12 of 21 patients). Our experience demonstrates that resection of tracheal stenosis and end-to-end anastomosis can be achieved successfully even in cases with stenosis of more than 30 % of the total tracheal length. The use of CBP allowed extensive mobilization of the tracheobronchial tree and resection with end-to-end tension-free anastomotic reconstruction.

Postintubation Multisegmental Tracheal Stenosis: Treatment and Results

A number of postintubation tracheal stenoses involve different and separate segments. Treatment of these types of strictures is complicated with obscure results, infrequently reported in literature. A total of 648 patients underwent treatment for tracheal or subglottic stenosis from September 1993 through October 2005; of those, 26 cases had two separate stenotic segments. Four types of therapeutic approaches were considered for these 26 patients: one-stage resection of the stenotic sites; two-stage resection of the stenotic sites; resection of one stricture and treatment of the second one by nonresectional methods such as dilatation, laser, stenting, T-tube, or tracheostomy; or treatment of both lesions by nonresectional methods. The therapeutic approach for each patient was determined by the surgeon and was based on the nature and location of stenoses, length of stenoses and the distance between the two stenotic sites. There were 20 male patients (76.9%) and 6 female patients (23.1%), with a mean age of 23.9 years (range, 4 to 64). Fourteen patients had tracheal stenosis and 12 had both tracheal and subglottic involvement. Five patients underwent type 1 therapeutic approach whereas 4, 9, and 8 patients underwent types 2, 3, and 4, respectively. Mean length of resection was 58.9 mm in those who underwent complete resection of the stenotic sites (range, 30 to 90 mm). There were 2 complications, 1 stomal fistula and 1 wound infection. Follow-up was accomplished in all patients with a mean period of 21.5 months (range, 1 to 108). Sixteen patients achieved satisfactory results (good voice and airway), 7 are still under treatment (requiring stent, tracheostomy, or repeated dilatation), and 3 died (2 type 3 and 1 type 4). Two deaths were due to T-tube obstruction, and 1 was due to acute obstruction of the stenotic part. Resection of both strictures and reconstruction of airway are feasible in some patients with multisegmental tracheal stenosis with good results. When resection of both strictures is not feasible, a combination of resectional and nonresectional managements could be helpful for the vast majority of patients.

Surgical treatment of aortic coarctation under normothermia without cardiopulmonary bypass: a report of 15 cases

To evaluate the early and mid-term outcome of surgical repair for post-ductal coarctation of the aorta (CoA) under normothermia without cardiopulmonary bypass. Clinical data from 15 patients (11 males, 4 females, mean age 18 +/- 10 years) undergoing surgical repair for post-ductal CoA under normothermia without cardiopulmonary bypass between January 1999 and December 2004 were analyzed retrospectively. There were 7 isolated cases, 7 cases associated with patent ductus arterious (PDA), 1 case with PDA and ventricular septal defects. Operation was performed under normothermia with partial cross-clamping of descending aorta in 8 cases, compete cross-clamping in 6 cases and temporary shunt in 1 case. Operative techniques adopted prosthetic bypass graft in 9 cases, Gore-Tex patch graft aortoplasty in 4 cases and stenosis resection with end-to-end anastomosis in 2 cases. PDA was ligated at single-stage in 8 cases. Ventricular septal defect was repaired at second stage in 1 case. No early and late death. Hypertension occurred in 9 cases during early postoperative period but was normalized gradually in 5 cases without medication during follow-up period, from 6 months to 5 years. The arterial blood pressure of lower extremities increased significantly and no hoarseness, paraplegia occurred after operation. No recoarctation and aneurysm formation were found during follow-up. Surgical repair of post-ductal CoA under normothermia without cardiopulmonary bypass is safe and effective, which is a procedure of choice for patients with isolated CoA, CoA associated with PDA, or with other intracardiac anomalies that are ready to be repaired at second-stage.

Observation on the long-term complications after esophageal replacement with colon

To study the etiology and preventive measures of the long-term postoperative complication after esophageal replacement with colon for esophageal benign disease. To review the clinical data of 577 patients with esophageal replacement with colon our department, including 123 cases of esophageal benign disease. Of all, there were 25 cases-time for 11 cases following with severe complication: redundancy and dilated colon 12 cases-time, severe stricture of stoma 4, macrocyst esophagus 2, colon-stomach stoma expansion 4, mechanical obstruction of colon 3. The etiology included iatrogenic and functionality. The therapy included stricture form or resection, redundancy segment resection, obstructed segment solution and stoma resection and form. Eight cases underwent once operation, 2 case twice, 1 case three times. After operation, 9 cases took food normally, 2 improved symptoms obviously. The iatrogenic and functionality factor contributed to severe complication after esophageal replacement with colon for esophageal benign disease. The preventive measure is followed during operation: cervical esophageal-colon anastomosis exceed 2.5 centimeter, abdominal colon-stomach anastomosis reflux, channel width of colon passage, intestinal canal lay up straight. Re-operation is best choice to for local stricture, colon expansion, redundancy and dilated colon.

Bilateral congenital midureteric stricture

Midureteric stricture is a rare cause of congenital hydronephrosis. Its etiology and pathophysiology is uncertain. We report a case of an 8 year old male child who presented with recurrent urinary tract infections and moderate renal impairment. Sonar revealed bilateral hydronephrosis. This was confirmed to be due to intrinsic midureteric narrowing on MRU. Bilateral ureteric exploration confirmed these findings and uretero-ureterostomy was performed. Postoperative imaging showed improvement in hydronephrosis. We review the published literature. CASE REPORT An 8 year old boy was admitted to our institution with a documented UTI. He had no significant past medical history. Physical examination was non-contributory. He was in moderate renal impairment with a serum Creatinine of 130mmol/l and an estimated Creatinine Clearance, using the Schwartz formula, of 50ml/min/m?. Urine cultures for Tuberculosis were negative. Renal sonar revealed gross bilateral hydroureteronephrosis with thin renal cortices. The bladder appeared normal. Of note no ureteric dilatation was seen at the level of the bladder. An MCUG revealed a normal bladder and posterior urethra with no reflux. Radioisotopic mercaptoacetyltriglycine (MAG3) renography showed poor uptake bilaterally with apparent holdup at the midureteric level. In view of the unusual imaging and to exclude extrinsic retroperitoneal pathology a Gadolinium enhanced magnetic resonance urogram was requested. This showed no retroperitoneal pathology, but bilateral midureteric obstruction. (See Figure 1). Figure 1 Figure 1: Gadolinium enhanced magnetic resonance urogram demonstating midureteric obstruction. Retrograde pyelograms revealed a tight, short-segment, nonnegotiable stricture at the level of the pelvic brim bilaterally. (Figure 2) Bilateral congenital midureteric stricture 2 of 3 Figure 2 Figure 2: Left retrograde pyelogram showed a pelvic brim stricture. Bilateral extraperitoneal ureteric exploration was performed using a Gibson incision. On both sides a similar appearance was seen. The stricture was excised revealing a pin-hole lumen. No valves or polyps were noted intraluminally. Stented ureter-ureterostomy was performed without tapering. The child made an uneventful recovery. Followup sonar at 3 months showed improvement in hydronephrosis bilaterally. Pathological review revealed proximal dilatation with nonspecific thickening of the muscular wall. Electron microscope evaluation of the strictured area showed no specific ultrastructural abnormality. DISCUSSION Congenital midureteric stricture is an uncommon cause of hydronephrosis in children. Less than 20 pathologically confirmed cases are reported in the literature. (2) The diagnosis may be confused with ureteropelvic or ureterovesical junction obstruction. Hence, retrograde pyelography is essential in the management of this anomaly. The differential diagnosis must additionally include ureteral valves and fibroepithelial polyps. Ectopic ureter and contralateral renal agenesis have been associated with some of the published cases. (2,4) The bilateral nature of our case would lend support to Kropp's assertion that contalateral agenesis and bilaterality point to the manifestation of a similar pathological process in this condition. (2) The cause of congenital midureteric stricture, however, remains unknown. Docimo postulated a variety of etiologic possibilities: 1) improper ureteric recanalisation, 2) insufficient vascular supply, 3) persistent ureteric folds, 4) ureteric bud anomalies. (3) It has been postulated that this condition runs a more aggressive natural history than other causes of congenital hydronephrosis. (2) This feature is born out by our case where longstanding obstruction resulted in renal impairment.

Laparoscopic Resection of Esophageal Stricture with Transgastric Stapled Anastomosis in a Child with AIDS

A tight stricture in the lower esophageal stricture in a child poses significant surgical challenges. We report the first case of a laparoscopically assisted resection of a distal esophageal stricture in a 2-year-old girl with clinical AIDS (CDC stage 3). The patient presented with dysphagia, vomiting, and progressive weight loss. A barium swallow confirmed a distal tight esophageal stricture in the lower esophagus. After the second dilatation attempt failed a gastrostomy was inserted and highly active antiretroviral therapy treatment commenced. Follow-up contrast studies showed a nearly complete obstruction of the distal esophagus. A laparoscopically assisted resection of the esophageal stricture with a primary stapled anastomosis was performed with good results. At follow-up 8 months postoperative the child was tolerating feeds well and thriving.

Abstracts for the British Congenital Cardiac Association Annual Meeting: The Barbican, London, 24–25 November 2005: Oral Presentations: Early and midterm outcomes of Implantable Cardioverter Defibrillator (ICD) implantation in patients with repaired Tetralogy of Fallot and pulmonary stenosis – a retrospective review

Introduction: Repair of Tetralogy of Fallot up until recent decades involved aggressive resection and annular enlargement through a right ventriculotomy. This resulted in ventricular scarring and pulmonary incompetence, with an increased risk of ventricular tachyarrhythmia and sudden death in young adulthood. Following the NICE guidelines, implantation of ICDs as primary prevention in patients with repaired Tetralogy is ever increasing. This study aims to determine the rate of appropriate and inappropriate discharges, the success rate of ICD therapy and the impact of ICD implantation on the use of anti-arrhythmic medication in this population of patients. Materials and Methods: This is a retrospective review of patients with repaired Tetralogy of Fallot (n = 18) and pulmonary stenosis (n = 2) with implantable cardioverter defibrillators managed at our tertiary centre. Patients were identified from our outpatient database, their notes and charts were examined and details regarding indication for ICD implantation, device specifications and complications following implantation were collected. Data was also collected on the incidence of appropriate and inappropriate therapies and the success rate of ICD therapy along with the impact of implantation on the usage of anti-arrhythmic medication in these patients. Results: Of the 20 patients, 18 had previous repair of Tetralogy of Fallot and 2 had pulmonary valvotomy and infundibular resection for pulmonary stenosis between 1969 and 1989. 70% (n = 14) of these patients required reoperation with 10 patients having pulmonary valve replacements (PVR), 3 having redo infundibular resections and 1 requiring aortic valve replacement. At the time of consideration for ICD implantation 80% had moderate to severe pulmonary incompetence and 60% had more than mild right ventricular dilatation on echocardiography. Indications for ICD implantation were symptomatic ventricular tachycardia requiring cardioversion (n = 8), ventricular tachycardia on 24 hr tape/Reveal or electrophysiological study (n = 8), ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT) (n = 2) and syncope with an abnormal EPS other than VT (n = 2, high grade ventricular ectopics, sinus node dysfunction).The median age at implantation was 22 years (16.4–43 years). All our patients had dual chamber devices implanted with either dual (n = 13) or single coil (n = 6) ventricular leads. GEM3 AT (n = 5), Marquis DR (n = 8) and Maximo DR (n = 7) generators (Medtronic Inc.) were implanted in sub pectoral position and both anti-tachycardia pacing and cardioversion modes were programmed as part of individualised VT and VF protocols. Early post procedural complications included atrial lead displacement (n = 1) and pneumothorax requiring drainage (n = 1).During a median follow up of 1.6 years (0.03– 4.5 years) several episodes of inappropriate therapies were noted in 6 patients (30%) especially early after implantation. This was found to be mainly due to atrial tachyarrhythmia, double counting of T waves or inaccurate interpretation of varying PR intervals as AV dyssynchrony which were effectively dealt with by changes in device programming. There were 33 episodes of inappropriate anti-tachycardia pacing (ATP) in 4 patients and 19 episodes of inappropriate cardioversion in 5 patients. Appropriate ATP was instituted in 4 patients (25%) with successful termination of all 20 episodes (100% success rate) of ventricular tachycardia. One patient required cardioversion with successful termination of VF. One patient (5%) with troublesome tachyarrhythmia died suddenly of unknown cause, 10 months after AICD implantation having had no detections or therapies on his device.Prior to ICD implantation 8 patients were on amiodarone therapy. At the time of last follow up after AICD implantation all patients were established on anti-arrhythmic agents and of these 6 patients were on amiodarone with the others being effectively managed on beta-blockers and/or flecainide.Late complications of ICD implantation included lead failure in 1 patient requiring replacement 3.3 years after implantation and generator replacement in a patient who was pacemaker dependent a year after implantation due to an advisory issued by the manufacturer regarding the risk of sudden battery depletion. Conclusions: In our study we found a rate of 0.6 appropriate and 1.4 inappropriate therapies (0.9 episodes of inappropriate ATP and 0.5 episodes of inappropriate cardioversion) per patient-year of follow up following ICD implantation which is in keeping with published literature. The mortality in our study group was 5% which is acceptable given the high risk population. Implantation of an ICD allowed switching over from amiodarone to less toxic anti arrhythmic therapy in a proportion of patients. Anti-tachycardia pacing was very successful in terminating tachyarrhythmia in our population with 100% success in terminating ventricular tachycardia.

Sténose congénitale de l'œsophage par hétérotopie trachéobronchique : à propos de 2 cas et revue de littérature

Congenital esophageal stenosis due to tracheobronchial remnants is a rare malformation whose diagnosis may be difficult. It is characterised by the abnormal presence of congenital tissue of tracheal origin in the esophageal wall, which is responsible for the narrowing of the esophagus. We report 2 cases whose treatment was surgical after failure of esophageal dilations. The presence of tracheal-bronchial tissue was confirmed by histological examination of the operative piece. Outcome was favourable and the final result was excellent. Recently, endoscopic ultrasonography has been proved useful in the diagnosis of congenital esophageal stenosis due to tracheobronchial remnants by showing the presence of cartilage, which explains the failure of dilation. The high rate of perforation in these cases is due to brutal fragmentation of the cartilaginous rings. Surgical resection of esophageal stenosis with the tracheobronchial tissue appears the only treatment susceptible to completely suppress the stenosis and its consequences.