369 Mono-orifice mitral valve after transcatehter repair with mitraclip system

A 70 years old male with non-ischaemic dilated cardiomyopathy (left ventricular end-diastolic volume, LVEDV, 200 mL), reduced left ventricular ejection fraction (LVEF, 30%) and worsening dyspnoea was screened for transcatheter repair of severe mitral regurgitation (MR). Baseline echocardiogram showed marked symmetrical bi-leaflet tethering with a symmetrical central jet. Etiology was predominantly functional with organic features including partial flail scallop (A1) and a ruptured second order chorda (Figure 1A). Pre-operative strategy was to deploy a single MitraClip NT in the central position. After correct deployment of the first clip, we observed a remarkable reduction of regurgitant jets in the lateral position accompanied by a complete holosystolic lack of leaflet coaptation in the medial orifice which caused significant residual regurgitation. (Figure 1B) MitraClip deployment in the commissural position is associated with technical challenges, including limited maneuvering, risk of chordae rupture and inability to retrieve the device if entangled. (1) Therefore, after careful crossing of the medial neo-orifice and rapid positioning a second MitraClip NT was implanted medial to the first device in the commissural position (Figure 2). As a result, the medial orifice was obliterated resulting in an atypical mono-orifice morphology which resembles a commissural edge-to-edge plasty. Anterograde flow was normal (G med 2.5 mmHg) and the trivial residual jet of MR was lateral to the two clips implanted. At 1-year follow-up the patient was asymptomatic (NYHA functional class I) with a stable mild MR and no change in anterograde gradients; positive remodelling of the left ventricle (LVEDP: −48 ml) and increased LVEF (+8%) were observed. 369 Figure 1.

Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma

Background Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. Methods The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). Results From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. Conclusion The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be “lost arts” in modern trauma care.

Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

The German CArdioSurgEry Atrial Fibrillation Registry: In-Hospital Outcomes

Background The aim of this study was to describe outcomes of patients undergoing surgical ablation for atrial fibrillation (AF) as either stand-alone or concomitant cardiosurgical procedures in Germany. Methods Patients with AF undergoing concomitant or stand-alone surgical ablation were included in the registry. Cardiac surgery centers across Germany were invited to participate and sought to enroll 1,000 consecutive patients. Data was obtained through electronic case report forms. The protocol mandated follow-up interviews at 1 year. Results Between January 2017 and April 2020, 17 centers enrolled 1,000 consecutive patients. Among concomitant surgical patients (n = 899), paroxysmal AF was reported in 55.4% patients. Epicardial radio frequency (RF) bilateral pulmonary vein isolation (PVI) with excision of the left atrial appendage (LAA) was the most common operative strategy. In the stand-alone cohort (n = 101), persistent AF forms were reported in 84.1% of patients. Moderate-to-severe symptoms were reported in 85.1%. Sixty-seven patients had previously underwent at least two failed catheter ablative procedures. Thoracoscopic epicardial RF bilateral PVI and completion of a “box-lesion” with LAA closure were frequently preformed. Major cardiac and cerebrovascular complications occurred in 38 patients (4.3%) in the concomitant group. No deaths were reported in the stand-alone group. At discharge, sinus rhythm was achieved in 88.1% of stand-alone and 63.4% concomitant patients. Conclusion The CArdioSurgEry Atrial Fibrillation registry provides insights into surgical strategies for AF ablation in a considerable cohort across Germany. This in-hospital data demonstrates that concomitant and stand-alone ablation during cardiac surgery is safe and effective with low complication rates.

Extrapial Hippocampal Resection in Anterior Temporal Lobectomy: Technical Description and Clinical Outcomes in a 62-Patient Case Series

BACKGROUND Anterior temporal lobectomy (ATL) is the most effective treatment for drug-resistant mesial temporal lobe epilepsy. Extrapial en bloc hippocampal resection facilitates complete removal of the hippocampus. With increasing use of minimally invasive treatments, considering open resection techniques that optimize the integrity of tissue specimens is important both for obtaining the correct histopathological diagnosis and for further study. OBJECTIVE To describe the operative strategy and clinical outcomes associated with an extrapial approach to hippocampal resection during ATL. METHODS A database of epilepsy surgeries performed by a single surgeon between October 2011 and February 2019 was reviewed to identify all patients who underwent ATL using an extrapial approach to hippocampal resection. To reduce confounding variables for outcome analysis, subjects with prior resections, tumors, and cavernous malformations were excluded. Seizure outcomes were classified using the Engel scale. RESULTS The surgical technique is described and illustrated with intraoperative images. A total of 62 patients met inclusion criteria (31 females) for outcome analysis. Patients with most recent follow-up <3 yr (n = 33) and >3 yr (n = 29) exhibited 79% and 52% class I outcomes, respectively. An infarct was observed on postoperative magnetic resonance imaging in 3 patients (1 asymptomatic and 2 temporarily symptomatic). An en bloc specimen in which the subiculum and all hippocampal subfields were preserved was obtained in each case. Examples of innovative research opportunities resulting from this approach are presented. CONCLUSION Extrapial resection of the hippocampus can be performed safely with seizure freedom and complication rates at least as good as those reported with the use of subpial techniques.

Management of Bilateral Spontaneous Pneumothorax Related to COVID-19 Infection

Spontaneous pneumothorax is a rare but potentially fatal complication of coronavirus infection and COVID-19 pneumonia. Data is limited to guide clinicians in the setting of spontaneous pneumothorax when conservative management fails and operative intervention is required. We report the clinical course and operative strategy for a patient who presented with sequential bilateral spontaneous pneumothorax after being diagnosed with severe COVID-19 pneumonia. Conservative management with bilateral tube thoracostomies failed to resolve persistent alveolar-pleural fistulae, and ultimately the patient recovered after synchronous bilateral VATS blebectomies in the operating room. The timing and treatment of spontaneous pneumothorax requires follow-up education and surveillance for patients with this disease, as lack of prompt treatment outside the hospital could increase patient mortality. Spontaneous pneumothorax is a concern in patients who re-present with recurrent symptoms after COVID-19 diagnosis. When conservative treatment fails, surgery can safely be performed in COVID-19 patients with simultaneous bilateral pneumothorax with full functional recovery.

Placental Types and Effective Perinatal Management of Vasa Previa: Lessons from 55 Cases in a Single Institution

Background: We aimed to identify clinical characteristics and outcomes for each placental type of vasa previa (VP). Methods: Placental types of vasa previa were defined as follows: Type 1, vasa previa with velamentous cord insertion and non-type 1, vasa previa with a multilobed or succenturiate placenta and vasa previa with vessels branching out from the placental surface and returning to the placental cotyledons. Results: A total of 55 cases of vasa previa were included in this study, with 35 cases of type 1 and 20 cases of non-type 1. Vasa previa with type 1 showed a significantly higher association with assisted reproductive technology, compared with non-type 1 (p = 0.024, 60.0% and 25.0%, respectively). The diagnosis was significantly earlier in the type 1 group than in the non-Type 1 group (p = 0.027, 21.4 weeks and 28.6 weeks, respectively). Moreover, the Ward technique for anterior placentation to avoid injury of the placenta and/or fetal vessels was more frequently required in non-type 1 cases (p < 0.001, 60.0%, compared with 14.3% for type 1). Conclusion: The concept of defining placental types of vasa previa will provide useful information for the screening of this serious complication, improve its clinical management and operative strategy, and achieve more preferable perinatal outcomes.

Management of Complex Pelvic Fracture with Associated Both Column Acetabular Fracture Judet-Letournel Type and a Coccygeal Fracture in a Severe Polytrauma Patient

Comprehensive emergency managements and early stabilization are pivotal upon treating complex pelvic and acetabular fractures. A thorough operative strategy is required to determine the best operative approach based on the patient’s general condition, available facilities, and surgeon preferences in such complex fracture configuration. Advanced technique of the fixation is necessary during a skillful execution of surgery in order to achieve good treatment results. An 18-years-old female crushed by a bus upon crossing street, presented with hypovolemic shock with ISS polytrauma score 50 consisting of right acetabular associated both column fracture, bilateral pelvic fracture anteroposterior compression type 3, and coccygeal fracture with bilateral drop foot. She underwent emergency laparotomy, had her ovary, bladder, and intestine primarily sutured, and then we immobilized the pelvic using anterior frame external fixator, which was maintained for 6 days. Upon stable condition, we performed right ilioinguinal approach and modified Stoppa with lateral window for the left side, while Kocher-Langenbeck technique was used to approach the posterior acetabular column. Postoperative radiology showed an adequate internal fixation in both right acetabular columns, successful reconstruction of pelvic ring which was fixated the left ischium, left superior and inferior pubic rami, and full restoration of left sacroiliac joint disruption. Majeed pelvic outcome score was 54, while Hannover pelvic outcome score was good and the patient was able to sit without pain 2 months postoperative. Management of complex pelvic-acetabular-coccygeal fracture requires a holistic chain of treatment by emphasizing the prompt emergency management, accurate preoperative planning, and excellent execution of reconstructive surgical strategy to achieve satisfactory outcome.

Challenges and operative strategy in an unusual case of giant mastoid osteoma

A 19-year-old female patient presented to the outpatient department of ear, nose and throat with complaints of hard swelling behind her left ear for the past 5 years. It was a large bony swelling arising from the left temporal bone causing a cosmetic deformity that was surgically excised. The patient made a good recovery post procedure. Histopathology confirmed the lesion to be osteoma.