Biomedical subjects
Publications and source records attributed to J B Eng.
A 16 year-old man presented with fracture of both his femurs after a road traffic accident. Chest radiograph revealed mediastinal widening. Subsequent CT scan and arch aortogram confirmed the findings of traumatic aortic arch transection at the isthmus. He underwent successful surgical repair. High index of suspicion and prompt actions are important in managing this potentially fatal but treatable condition.
To assess the efficacy of the trans-septal approach to the mitral valve, 40 patients who underwent mitral valve surgery via this approach were compared to 37 patients who underwent surgery via the standard left atriotomy. Concomitant procedures included tricuspid annuloplasty, aortic valve replacement, closure of atrial septal defect, coronary artery bypass grafting and aortic valve repair. There was one (1.2%) operative mortality. No patients required pacemaker implantation. Follow-up of up to 18 months showed that all patients were in NYHA classes I and II. One third of the patients who had trans-septal approach to the mitral valve achieved conversion from atrial fibrillation to sinus rhythm while none of the patients who underwent conventional left atriotomy had conversion (p < 0.02). The trans-septal approach to the mitral valve is a useful approach in selective patients requiring mitral valve surgery.
Patients with upper airway obstruction from malignant disease are difficult to manage. A 62 year old patient presented with stridor and was found to have an upper tracheal tumour. Bronchoscopy, dilatation and stenting were performed successfully. The techniques and indications for the use of dynamic airway stent are discussed.
One hundred and ten patients underwent gastroesophageal resections performed transdiaphragmatically by way of a left thoracotomy. Eighty-one patients had tumors distal to the inferior pulmonary vein and had en bloc dissections, while the remaining 29 had midthoracic tumors, which required a two-rib thoracotomy. There were 73 men and 37 women with a median age of 64 years (a range of 40 to 75 years). The postoperative mortality rate was 2.7 per cent, and morbidity, mainly caused by respiratory complications, occurred in 21 patients (19 per cent), with no patients requiring ventilatory support. There were no anastomotic leaks. Adequate analgesia was provided by the use of a subpleural catheter delivering a continuous infusion of bupivacaine. The left thoracotomy provides an effective method for undertaking esophageal resections with low mortality and morbidity rates. This approach should be more widely used in the surgical management of patients with intrathoracic esophageal tumors.
Others have demonstrated the effectiveness of intercostal analgesia with bupivacaine hydrochloride (Marcain Plain; Astra). We present a greatly simplified method of effecting this. Our method is dependent on an intact pleura. To date, we have utilized this technique in 81 patients. Seventy-five (92.6%) required no additional analgesic in the first 24 hours following operation and 66 (81.5%), in the subsequent four days. Only 2 patients had postoperative pulmonary complications. No complication related either to the procedure or to the infusion of bupivacaine occurred. The technique as described here is a safe and reliable method of providing analgesia without any side effects after thoracotomy.