A rare association of bilateral atrial divisions and quadricuspid aortic valve.

BACKGROUND: Quadricuspid aortic valve and cor triatriatum are rare congenital cardiac anomalies. METHODS: We describe a rare case of quadricuspid aortic valve with dividing membranes in the left and right atria. RESULTS: The patient underwent surgery with resection of the dividing membrane in the left atrium and aortic valve replacement. CONCLUSION: Management is based on symptoms of obstruction due to the dividing membranes in the atria and the severity of aortic valve dysfunction. This case also highlights the limitations in current nomenclature when describing atrial partitions.

A black heart: Aortic valve ochronosis secondary to alkaptonuria causing aortic stenosis.

Alkaptonuria is a rare autosomal recessive genetic disorder where an accumulation of homogentisic acid in the tissues leads to ochronosis-a pathological dark pigmentation. It can affect various tissues and the weight bearing joints of the body, leading to degenerative arthropathy. On the rare occasion, it causes cardiac manifestations. We describe a case of aortic valve stenosis due to ochronosis secondary to alkaptonuria requiring aortic valve replacement.

Tissue "valve-over-valve" implantation in previous mechanical Bentall.

Multiple studies have reported the adverse impact of audible clicks from mechanical heart valves on the quality of life. Sadly, this can become a lifelong liability in younger patients necessitating explantation. Bioprosthetic valve replacement is the treatment for this distressing condition associated with an isolated mechanical valve. However, patients who have undergone a mechanical Bentall's procedure represent a unique surgical challenge. In view of the significant complications associated with a redo aortic root operation, the alternative of a "valve-over-valve" implantation is an attractive option that might present reduced morbidity. We report a unique case of valve noise intolerance in a patient who underwent a bioprosthetic valve-over-valve replacement following previous Bentall's procedure with a mechanical valved conduit.

How to do whole lung lavage for treatment of pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis is a rare condition characterized by progressive accumulation of surfactant lipoproteins in the alveolar space, leading to poor gas exchange. We describe our technique of whole lung lavage for management of pulmonary alveolar proteinosis.

Internal herniation following laparoscopic gastric bypass: addressing the mesoclosure technique.

A 49-year-old man presented with a 2-week history of gradual onset progressively worsening left upper quadrant pain. Ten months prior, he had a laparoscopic roux-en-Y gastric bypass (LRYGBP) for severe gastro-oesophageal reflux disease and obesity. On examination, his abdomen was not distended and was soft to palpation. The haemoglobin, white cell count, liver function test, lipase and lactate were normal. An abdominal CT scan demonstrated swirl sign. Given the suspicion of internal herniation, laparoscopy was performed demonstrating only partial closure of the jejuno-jejunal mesodefect resulting in herniation of the small bowel alimentary limb. Internal herniation should be considered as a differential diagnosis in all patients with previous LRYGBP and unexplained abdominal pain, nausea or vomiting. If closure of a mesodefect is to be attempted, a running, braided, non-absorbable suture should be used as a purse-string to avoid small defects with subsequent weight and mesenteric fat loss following bariatric surgery.

How to do a simplified Dacron sleeve technique of aortic anastomosis.

Step-by-step diagram demonstrating technique of Dacron sleeve anastomosis for thoracic aorta.

Extrahepatic bile duct injury in blunt trauma: A systematic review.

BACKGROUND: Extrahepatic bile duct injuries (EHBDIs) are a rare consequence of blunt abdominal trauma. The purpose of this study was to establish mechanisms of injury, clinical indicators of EHBDI following blunt trauma (both with investigative modalities and intraoperatively), method and timing of injury detection, and definitive treatment options. METHODS: A systematic review was performed to gather data on patients with an EHBDI secondary to blunt trauma. Three databases (MEDLINE, PubMed, and EMBASE) were searched to July 19, 2018. RESULTS: Our systematic review included 51 studies, compromising a study population of 66 patients with EHBDIs sustained from blunt trauma. The three most common injuries included complete transection of the suprapancreatic common bile duct (29%, n = 19), complete transection of the intrapancreatic common bile duct (23%, n = 15) and partial laceration of the left hepatic duct (20%, n = 13). Of the hemodynamically stable group managed nonoperatively (n = 23), mean timing postinjury to diagnosis of EHBDI was 11 days. An EHBDI was recognized at initial laparotomy in 87% (n = 13) of hemodynamically stable patients. An EHBDI was recognized at initial laparotomy in 57% (n = 8) of hemodynamically unstable patients. CONCLUSION: The EHBDIs are a rare yet serious consequence of blunt trauma. To establish a timely diagnosis and limit complications of missed injuries, a heightened awareness is required by the attending surgeon with particular attention to subtle yet important clinical indicators. These vary depending on the hemodynamic stability of the patient and decision to manage injuries conservatively or surgically on presentation. LEVEL OF EVIDENCE: Systematic review, level III.