Annuloplasty and aortoplasty as modifications of the Ross procedure for the correction of geometric mismatch.

BACKGROUND AND AIM OF THE STUDY: Pulmonary autograft replacement of the aortic valve (the Ross procedure) is reliable and durable; however, geometric mismatch of the autograft and systemic outflow tract may lead to poor results. Manipulation of the aortic annulus and sinotubular diameters to match the autograft can prevent geometric mismatch, and improve results. METHODS: Annuloplasty and/or aortoplasty were combined with the Ross procedure in 26 of 44 patients (median age 42.5 years; range: 3 days to 62 years) undergoing surgery between April 1994 and July 1998. Plication of the aortic annulus at either two or three of the commissures was done in five cases, aortic annulus fixation with an external pericardial pledget incorporated in the proximal suture line in 12 cases, and tailoring aortoplasty in nine patients. RESULTS: There was one operative death. Two patients required reoperation; one for progressive autograft dysfunction and one for homograft dysfunction. Annular fixation was performed on the patient requiring reoperation for autograft dysfunction. Doppler echocardiography during the follow up (median 9 months; range: 1-50 months) revealed 10 patients with trace 1+ and one patient with 2+ aortic insufficiency. Trace 1+ and 2+ aortic stenosis were present in one patient each. None of the patients undergoing commissural plication had significant regurgitation or stenosis. Both patients with stenosis underwent annular fixation. Aortoplasty was associated with 1+ insufficiency in two patients. CONCLUSION: Prevention of geometric mismatch between the autograft and systemic outflow tract at the annulus and sinotubular junction by plication techniques allows better performance of the autograft, and extends the Ross procedure to patients who otherwise may be unable to undergo such surgery. Fixation may provide similar benefit, but appears to be more susceptible to insufficiency and stenosis.

Eosinophilic gastroenteritis presenting as an obstructing cecal mass--a case report and review of the literature.

The causes of colonic obstruction are protean. Less common is the diagnosis of eosinophilic gastroenteritis (EGE). EGE is more common as a cause of more proximal bowel obstruction. To our knowledge, this case represents one of the only reported cases of such a lesion causing obstruction in the cecum.

Purposeful delay in the repair of a traumatic rupture of the aorta with coexistent liver injury.

Purposeful delay in the repair of traumatic aortic injury by appropriate medical management is indicated when the risk of immediate thoracotomy is high. A grade V liver injury implies parenchymal disruption of greater than 75% of a hepatic lobe. We report the successful management of a patient with a class IB proximal descending aortic transection and concomitant grade V liver injury that precluded aortic repair until its resolution.

Timing of video-assisted thoracoscopic debridement for pediatric empyema.

BACKGROUND: Video-assisted thoracoscopic debridement (VATD) is a new method of managing pediatric empyema. The purpose of this retrospective study was to determine the relation between the timing of VATD and its success in avoiding the need for open decortication. STUDY DESIGN: Twenty-one children aged 3 to 16 years (mean, 8 years) with symptomatic, loculated, parapneumonic empyema were treated with VATD at two tertiary pediatric centers between 1994 and 1997. The preoperative duration of symptoms, hospitalization, and previous need for thoracostomy drainage were compared between patients having VATD only and those who subsequently required a thoracotomy and decortication. Statistical analysis used the Wald chi-square test or Fisher's exact test with p < 0.05 considered significant. RESULTS: Video-assisted thoracoscopic debridement was successful in 15 patients (group 1) and unsuccessful in six patients (group 2), who required a thoracotomy and decortication. Group 1 had a shorter mean duration of preoperative symptoms (13 versus 27 days; p=0.03), a shorter median duration of preoperative hospitalization (6 versus 18 days; p=0.04), and a lower incidence of previous thoracostomy drainage (4/15 versus 5/6; p=0.05). CONCLUSIONS: The technique of VATD is most likely to be successful when used within one week of diagnosis of a loculated parapneumonic empyema. A prospective trial comparing VATD with intrapleural fibrinolytic agents for the initial treatment of pediatric empyema is needed.