Ultrastructural Characteristics of the Orbicularis Oris Muscle in the Microform Cleft Lip

RecentIy, increasing emphasis has been placed on the histochemical and ultrastructural characteristics of the muscle in the cleft lip. Schendelet al and Cho et al demonstrated a non-neurogenic muscle atrophy and mitochondrial myopathy, and Raposio examined an increased inflammatory reaction, but no mitochondrial abnormalities of the cleft lip muscle. However, no study has focused on the ultrastructure of the microform cleft lip muscle. Eleven muscle specimens were obtained from the microform cleft lip patients at the time of primary repair from Jun.1997 to Aug.1998 and they were submitted to histologic and histochemical examinations as well as electron microscopy. A non-neurogenic muscle atrophy was seen on HE stain. Modified Gomori trichrome stain revealed red granularity of the muscle fibers, suggesting an increase in mitochondrial activity, however, no ragged-red fibers, a typical sign of mitochondrial myopathy, was found. Electron microscopy revealed atrophy, disarray, and focal loss of myofibrils, dilated sarcoplasmic reticulum with glycogen deposit, and interstitial fibrosis. However, the mitochondrial morphology was well preserved with an increase of the number of the mitochondria which might be secondary change to muscle degeneration. In conclusion, ultrastructural characteristics of the orbicularis oris muscle in the microform cleft lip is non-neurogenic muscle atrophy without mitochondrial myopathy which is controversial in the complete cleft lip.

Clinical Experiences and Considerations of Large-Volume Liposuction

A review of recent reports showed that many surgeons define large-volume liposuction as the removal of over 5000ml of total aspirate. However, no clinical reports of single procedures in Korean involving aspirate volume of 5000 ml or greater have been presented. From May 2002 to December 2004, 59 patients with age averaging 31.2 years old underwent large-volume liposuction. Liposuction was performed using the superwet technique and a Lipomatic(R) vibropneumatic system. Clinical data, which included; body weight changes and BMIs at a postoperative 2 months, hemoglobin and hematocrit at a postoperative 2 days, operative time, and volume of infiltrate and aspirate, were evaluated. The average volumes of infiltrate and aspirate were 6916.7+/-1665.8ml and 6549.6+/-1787.2ml, respectively. Mean patient weight had decreased from 62.96+/-14.21 to 58.61+/-13.43kg with an average weight loss of 4.35kg, and mean body mass index from 23.84+/-3.91 to 22.17+/-3.70kg/m2 with an average drop of 1.67kg/m2; equivalent to a fall in weight per liter of aspirated volume of 0.66+/-0.09kg/L. Falls in hemoglobin and hematocrit per liter of aspirate volume were 0.46+/-0.07g/dl/L and 1.70+/-0.35%/L, respectively. Mean operative time per liter of aspirate was 39.6+/-2.1min/L. Complications were palpable skin irregularity in 5 patients; hyperpigmentation scars occurred in 5 patients; 2 of the heaviest women required blood transfusions; and 1 patient experienced prolonged edema. One major complication of subclinical fat embolism occurred. Cosmetic results were generally good. In conclusion, if patients are properly selected and fluid resuscitations are performed adequately, single stage liposuction involving aspirations of greater than 5000ml can be undertaken safely in Korean.

Surgical Treatment of Tracheal Restenosis following Operation for Postintubation Tracheal Stenosis: Two cases report / 대한흉부외과학회지

The treatment of choice for post-intubation tracheal stenosis is partial tracheal resection and end-to-end anastomosis. The surgical treatment of tracheal restenosis that results from unsuccessful repair of post-intubation tracheal stenosis is not easy. Failed reoperation results in permanent tracheostomy and loss of voice. If the first operation fails, about 4~6 months of period for resolution of inflammatory reaction, edema, and fibrosis is needed. The exact evaluation of the patient's status is necessary and success rate of reoperation for the appropriate candidates is over 90%. We report the results of treatment in two cases of tracheal restenosis that resulted from unsuccessful repair of post-intubation tracheal stenosis with review of literatures.

Rapid Left ventricular Training after Arterial Switch Operation in Transposition of Great Arteries with Left Ventricular Outflow Tract Obstruction and ventricular Septal Defect: 1 case report / 대한흉부외과학회지

There have been few reports documenting the outcome of arterial swich operations(ASO) in selected patients with transposition of great arteries(TGA) and with left ventricular outflow tract obstruction(LVOTO). In the case of TGA with LVOTO, if the atrial septal defect(ASD) is large and the ventricular septal defect(VSD) is restricive, this deprives the left ventricle(LV) of approporiate preload and could lead to underdevelopment of the ventircular mass and lead poor LV performance after the arterial switch operation, dspite a high pressure in the LV preoperatively. Because an increase in the systolic ventricular pressure is not necessarily paralleled by an increase in ventricular mass, which is also essential for optimal ventricular performance after the operation. We report here a case of rapid LV training after ASO in TGA with unprepared LV (because of large ASD and restrictive VSD) despite a high pressure in the LV(due to LVOTO) preoperatively.

Transposition of great arteries with pulmonary stenosis and remote muscular inlet ventricular septal defect / 대한흉부외과학회지

We report a successful biventricular repair of D-transposition of great arteries, pulmonary stenosis and remote muscular inlet ventricular septal defect, after modifie Blalock-Taussing shunt early in infant. A long left ventricle-to-aorta intraventricular rerouting tunnel was created without stenosis by transferring the medial papillary muscle of the tricuspid valve to the tunnel, obliterating the trabeculation of right ventricle in the course of tunnel and excising the secondary chordae of the tricuspid valve.

The Clinical Experiences of Ultrasound-Assisted Lipo plasty

Suction-assisted lipoplasty is now flrequently-performed pre cedure in plastic surgery, but it has several drawback including bleeding contour irregularity due to its traumatic nature. The recently introduced ultrasound-assisted lipoplasty (UAL) technique uses ultrasonic energy which has specificity in lower density tissue like fat tissue. Therefore, UAL can minimize these compli cations. We performed UAL in 21 patients from OCt. 1988 to Jun 1999. There were 17 females and 4 males, and patient age ranged from 18 to 52 years(average 40 years). A total of 58 areas were operated on for an averge of 28 areas per patient. We used a fivestage technique consisting of tumescent infiltration, ultrasonund treatment, emulsion suction, endermology, and postperative pressuregarment application. Total volume (fluid and fat) removed ranged from 200 to 4,050 cc(averge 1,750 cc) per patient and the lipocrit within the aspirate was 4-8%, which was significantly lower compared with traditional liposuction Residual emulsion was evacuated by endermology and pressuregarment was applied to all patients for postoperative 2-3 months. Pestoperative complications were seroma, induration, and paresthesia, but all these problems resolved spontaneously within a month. One patient required secondary UAL for correction of excess fat at the medial knee. We believe that UAL is a safe and excellent technology in liposuction because of reduced surgical bleeding and good contral of body contour.

Repair of Complete Atrioventricular Septal Defect with Surgical Modification / 대한흉부외과학회지

BACKGROUND: Recent advances in understanding the anatomy of the complete atrioventricular septal defect(including right-dominant unbalanced atrioventricular septal defect) have led to alternative methods of repairing these defects. MATERIAL AND METHOD: From May 1997 to July 1998, 8 consecutive infants(age range, 2 to 28 months, mean body weight 6.0+/-2.2 kg) received a single-stage intracardiac repair of the complete atrioventricular septal defect with modified surgical methods. Depending on the specific anatomic structure, the procedure was simplified in 3 patients by a direct closure of the ventricular element of the defect(Group I). Two patients judged unsuitable for direct closure due to a potential left ventricular outflow tract obstruction had received a standard two-patch repair(Group II). The remaining 3 patients with right-dominant unbalanced complete atrioventricular septal defect underwent biventricular repair; to enlarge the orifice of the left atrioventricular valve, the ventricular septal patch was placed slightly more to the right of the ventricular crest, a left sided bridging leaflet was augmented with an autologous pericardial patch, and the leaflet was repaired with a double- orifice(Group III . RESULT: In all 8 patients, the postoperative echocardiography demonstrated good hemodynamics. Seven patients were weaned from the ventilators after a mean 3+/-1 days, and 1 patient was weaned after 24 days due to a reoperation and emphysematous lung problem. A reoperation was performed in 1 patient for progressive left atrioventricular valve regurgitation due to leaflet tearing. There were no early and late mortalities. At the time of the latest review, judging from the echocardiographic criteria, left atrioventricular valve stenosis was mild in 1 patient(mean pressure gradient 6.5 mmHg, 13.5%), left atrioventricular valve regurgitation was absent or grade I in 7 patients(87.5%). The right atrioventricular valve regurgitation was absent or grade I in all 8 patients(100%). CONCLUSION: Infants with complete atrioventricular septal defect were treated with either a simplified approach with direct closure of the ventricular element of the defect or a modified surgical technique for a right-dominant unbalanced atrioventricular septal defect, depending on the anatomic structure. The results were no operative mortalities and low morbidity.

Early result of Coronary Artery Bypass Grafting Using the Internal Thoracic and the Radial Arteries / 대한흉부외과학회지

BACKGROUND: Increasing interest in the use of arterial conduites is based on the better patency of the internal thoracic artery(ITA) than the saphenous vein graft and the hope that other arterial conuits will perform similarly over the long term. MATERIAL AND METHOD: Between May 1997 and July 1998, 43 patients underwent coronary artery bypass grafting with ITA and the radial artery(RA). There were 28 men and 15 women with a mean age of 61.5 years(range, 35 to 78). In 43 patents, 30 bilateral ITA(including 7 diabetes mellitus, 5 more older 70 years), 8 bilateral ITA only, 2 left ITA and both RA, 11 left ITA and left RA and 22 both ITA and left RA were used. RESULT: There was 1 hospital mortality. Of the 42 patients alive, 39 patients are asymptomatic. Postoperative complications were postoperative bleeding in 1 patients, and low cardiac output syndrome in 3. Follow-up angiography was performed in 5 patients after the operation(mean 3 months), and all ITA & RA grafts showed excellent results. CONCLUSION: We conclude that complete arterial revascularization with internal thoracic artery and radial artery is technically feasiale with low mortality and morbidity, and but long term follow-up is needed.

Reconstruction of Injured or Inadquate Left Internal Thoracic Artery in Cornonary Artery bypass Graft / 대한흉부외과학회지

BACKGROUND: Use of the left internal thoracic artery(ITA) to bypass the left anterior descending(LAD) coronary artery has become the standard of care based on its superior graft patency, reduced cardiac events, and enhanced survival. But rarely we encountered with injury to the artery during harvesting which leads to loss of the merits of surgery. We reconstructed inadequate ITAa with other arterial conduits so proximal stump to be a blood source if possible. MATERIAL AND METHOD: Between January 1996 and March 1999, 12 patients received bypass with the reconstructed left internal thoracic artery grafts to left anterior descending artery because of an injury(n=8), short or small(n=4). Right or left ITA was used to LAD as a free graft(n=2). And the other 10 left ITAs were extended with radial artery(n=6), right ITA(n=3), saphenous vein(n=1). Composite "T" graft was made with other arterial conduits in these extended graft(n=5). RESULT: There was only one morbidity of minor would problem, and no mortality. The patency of extended graft to LAD was complete in 5 patients who received angiography during the period of 2wks to 2 years postoperative, but one of side branch of "T" graft occluded. All of these patients were well. CONCLUSION: Reconstructive extension with the use of other arterial conduit for the injured proximal ITA is warranted in any patients with acceptable results.

Anatomical Repair of Congenitally Corrected Transposition with Apicocaval Juxtaposition: 1 case report / 대한흉부외과학회지

Over the past several years, a number of centers have reported favorable results of anatomical repair for the congenitally corrected transpositions. However, there have been subsequent problems related mainly to the results of atrial switch procedures in patients who had small atriums because of venoatrial obstructions or supraventricular arrhythmias, especially in patients with apicocaval juxtaposition. Cavopulmonary shunt may be a useful addition to the double switch operation in certain circumstances as a means of avoiding potential atrial complications. Herein, we describe the successful anatomical repair of congenitally corrected transposition of the great artery with pulmonary atresia, ventricular septal defect, and cavo apical juxtaposition with this modification.

Clinical Experiences of The Chest Wall Reconstructions

Reconstruction of chest wall defects has been a continuing challenge to surgeons. Defects due to resection of tumors, infection, radiation injuries, and congenital anomalies may require chest wall reconstruction. Recent advances in plastic surgery have made reconstruction of the chest wall a reliable procedure. We reviewed fourteen consecutive chest wall reconstructions except mediastinitis over the past eight years. Among the patients, ten patients had chest wall tumors and remaining four patients had radiation necrosis, pressure sore, Poland's syndrome and Tuberculous empyema. Skeletal resection of the chest wall was done in six patients; Total or partial stemectomies were performed in three patients and an average of three point six ribs were resected in six patients. Soft tissue resection was performed in twelve patients. After resection, the thoracic skeletal defect was reconstructed with polypropylene mesh (Marlex) alone in one patient, with a composite of polypropylene mesh (Marlex) and methyl metacrylate in two patients, and with autogenous ribs in one patient. Soft tissue reconstructive procedures were predominantly muscle transpositions: five pectoralis major, three latissimus dorsi,two rectus abdominis and three fasciocutaneous flaps. Eleven patients who were alive after operation have protective and functional chest wall with excellent cosmesis at the time of last follow-up. We conclude that chest wall reconstructive procedures with prosthetic, or autogenous materials and musculocutaneous flaps are safe, durable and contributive to long-term survival and quality of life.

Clinical Experiences of MIDCAB - Developmental Stage and Early Short-term Results / 대한흉부외과학회지

BACKGROUND: Minimally invasive direct coronary artery bypass surgery(MIDCAB) has been increasing in interest along with the new techniques in myocardial immobilization for easier and safer procedures. Until the opening of the era of new techniques, adequate accuracy and good patency of grafts were debatable. Our experiences of MIDCAB were studied according to the stages of technical developments. Material and Methods: Since March 1996, 55 patients have undergone MIDCAB procedures. The patients of off-pump CABG(no cardiopulmonary bypass under full sternotomy) were excluded from the study. In the early experience(Stage I), a left anterior small thoracotomy through the left parasternal incision was performed(n=6); then an approach through the lower partial sternotomy was used(Stage II, n=33); and recently, a chest wall elevator for harvesting the internal thoracic artery and the foot plate for myocardial immobilization have been used(USSC, Norwalk, CT)(Stage III, n=16). RESULT: The surgical procedures of four patients in the Stage II group have been converted to conventional bypass because of the deeply seated left anterior descending coronary artery in two patients, fracture of the calcific lesion in the right coronary artery in one patient, and a cardiogenic shock during hypothermia in the other patient with ventricular dysfunction. Two patients in stage II experienced symptomatic recurrences after surgery and restenosis was verified on angiocardiography. They were managed by interventional procedures. All the other patients were doing well without symptoms, except one patients in Stage II who underwent PTCA procedure for a lesion in the circumflex artery during the follow up period. CONCLUSION: The new and specialized devices are essential to the development of MIDCAB surgery. MIDCAB and the hybrid procedures in multi-vessel disease are on the way to further development. So far, our experience is limited only to a single device among the many new devices for the purpose.

Early Results of Extracardiac Fontan Operation / 대한흉부외과학회지

Between August 1996 and August 1997, 22 patients underwent extracardiac Fontan operations. The basic diagnoses included univentricular heart of the right ventricular type (n=12); univentricular heart of the left ventricular type (n=4); tricuspid atresia (n=4); left isomerism, transposition of great arteries, ventricular septal defect and pulmonary stenosis (n=1); and criss-cross heart with uneven ventricle (n=1). The median age of the 14 men and 8 women was 29 months (range from 21 months to 26 years). Previous procedures included bidirectional cavopulmonary shunt (n=15, interval=15.6+/-3.4 months), Kawashima operation (n=4, interval=37.5+/-20 months), and classic Glenn shunt (n=1, interval=14 years). In 2 patients, extracardiac Fontan operations were done without any previous procedures. A 16-to 22-mm flexible Gore-Tex tube graft (n=18), Hemashield graft (n=3), or, alternatively, a nonvalved aortic allograft (n=1) was cut and anastomosed end-to-end between inferior vena cava and undersurface of pulmonary artery using Gore-Tex or Prolene suture in a running fashion. In risk Fontan patients (n=12), a communication between the extracardiac conduit and the right atrium was constructed. In the most 13 recent patients, the procedures were done without cross-clamping of the aorta and with a beating heart. Operative mortality was 9.1% (n=2). Complications included persistent chest tube drainage for more than 7 days (n=5), chorea (n=2), and low cardiac output (n=1). There were no late deaths. Follow-up echocardiogram (mean: 6 months) demonstrated satisfactory hemodynamic results in the surviving 20 patients. Potential advantages of this technique consist of minimization of surgical manipulation of atrial tissue, reduction or elimination of myocardial ischemia, creationof a uniform and stable inferior vena cava-to-pulmonary artery conduit, and increased flexibility and safety in certain high-risk patients such as those with increased pulmonary vascular resistance, pulmonary hypertension, and impaired ventricular function. Further investigations during a longer follow-up are needed to confirm the intermediate and long-term results, especially the reduction of late atrial arrhythmias.

Spontaneous Submucosal Dissection of the Esophagus: Report of 1 Case / 대한흉부외과학회지

A 55-year-old male was admitted to our hospital complaining of chest discomfort, dysphagia and severe pain on swallowing. Esophageal manometry showed that there was no relaxation of lower esophageal sphincter to swallowing. There was double barrelled esophagus or mucosal stripe appearance on esophagogram. Endoscopy revealed an appearance as if an esophago-tracheal fistula had been made at the level of the upper thoracic esophagus. Also, two slit-like mucosal tears was seen on the lower esophagus. There after, fasting and total parenteral nutrition for several weeks failed to bring about any changes in his symptoms. So, as treatment, primary closure of the upper opening of the false lummen was performed under general anesthesia. Soon after the surgical procedure, the patient's symptoms were improved except for mild dysphagia. He was discharged after oral intake had been juduciously commenced with fluids and soft diet subsequently. During follow-up in out-patient department, he had no specific symptoms including fever or dysphagia and massive dissection of the esophagus was improved on esophagogram. We report the experience of a case of spontaneous submucosal dissection of the esophagus which required conservative and surgical management.

Simplified Approach to Repair of Complete Atrioventricular Septal Defect / 대한흉부외과학회지

Recent advances in understanding the anatomy of complete atrioventricular septal defect have led to alternative methods of repairing these defects. Here we report two cases of complete atrioventricular septal defect repair by direct closure of the ventricular element of the defect. Follow-up for average of 3 months suggests that, when direct closure can be performed, the results can be comparable with those of the standard technique. Our initial success with this approach is encouraging; however, longer follow-up and more experiences are required to establish whether it will be broadly applicable.

Spontaneous Submucosal Dissection of the Esophagus: A case report / 대한소화기내시경학회지

A 55-year-old male was admitted to our hospital complaining of chest discomfort, dysphagia and severe pain on swallowing. Esophageal manometry identified the lower esophageal sphincter as having no response to swallow. Barium swallow showed typical esophagograms of double barrelled esophagus or mucosal stripe. An endoscopic examination revealed an appearance as if an esophago-tracheal fistula had been made at the level of the upper thoracic esophagus. Also, two slitlike mucosal tears were seen on the lower esophagus. Subsequent fasting and total parenteral nutrition for several weeks failed to bring about any improvement in his symptoms. So, as a treatment, primary closure of the upper opening of the false channel was performed under general anesthesia. Soon after the surgical procedure, the patients symptoms disappeared except for mild dysphagia. He was discharged after oral intake had been judiciously commenced with fluids and soft diets. During his follow-up in the out-patient department, he was examined and found to have no specific symptoms including fever or dysphagia. Moreover, there was great improvement from the massive dissection of the esophagus on esophagogram.

Use of the Native Aortic Valve as the Pulmonary Valve in the Ross Procedure / 대한흉부외과학회지

Aortic valve replacement in young patients has its problems. Biologic prosthetic valves degenerate and need replacement. Metalic prosthetic valves are more durable, however, anticoagulation which has its inherent problems is inevitable. The use of Ross procedure in young patients is gaining wider acceptance. The need of foreign pulmonary valve in right ventricular outflow tract (RVOT) will require reoperation due to RVOT obstruction, later. To overcome this problem, we reimplanted the native aortic valve in the pulmonary position in 21 year old female patient operated on utilizing the Ross procedure for aortic insufficiency. We experienced that the diseased aortic valve worked well in the pulmoanry position because of low pulmonary artery pressure and resistance.

Pulmonary Autograft Replacement in Native Aortic Root Abscess / 대한흉부외과학회지

Bacterial endocarditis of the native aortic valve is associated with significant morbidity and mortality despite aggressive medical and surgical treatment, especially when perivalvular tissue was invaded and destructed. The pulmonary autograft is full viable and immune compatible tissue. This paper describes successful Ross operation as total root replacement in 38 years old native valve endocarditis patient with aortic root abscess.

Surgical Repair of Ebstein's anomaly by Modified Carpentier's Method: 2 cases report / 대한흉부외과학회지

Ebstein's anomaly is a complex malformation that can be treated by various surgical techniques, either repair or replacement of the abnormal tricuspid valve, with variable results. The essence of the malformation is the downward displacement of the septal and posterior leaflets into the ventricle, resulting in the formation of an atrialized portion of the right ventricle. The aim of surgical repair is to correct the tricuspid valve dysfunction and to plicate the atrialized portion of the right ventricle A 12-months old female was admitted with the diagnosis of Carpentier type A of Ebstein's anomaly with severe tricuspid regurgitation. She successfully underwent operation with vertical plication of right ventricle and reimplantation of tricuspid leaflets. Postoperatively cardiac size was significantly reduced and tricuspid regurgitation was trivial in echocardiography. She was diacharged the 14th postoperative day.