Study Type -Therapy (outcomes research) Level of Evidence 2c OBJECTIVETo present total phalloplasty in children and adults using a musculocutaneous latissimus dorsi (MLD) free flap to create a large neophallus, that allows easy urethroplasty and implantation of a prosthesis. PATIENTS AND METHODSFrom April 1999 to January 2006, 16 patients (mean age 24 years, range 10-34) had a total phalloplasty; the indications were congenital anomalies of the penis in 12, iatrogenic in two and accidental penile trauma in two. The MLD flap is mobilized on a subscapular artery and vein, and a thoracodorsal nerve. The neophallus is created on-site and after dividing the neurovascular pedicle, transferred to the pubic region, where it is anastomosed with the femoral artery, saphenous vein and ilio-inguinal nerve. The donor site was closed directly in 15 patients while in one a split-thickness skin graft was used to cover the defect. In the following stages, two-or three-stage buccal mucosa urethroplasty was used in 11 patients; a penile prosthesis was implanted in seven. RESULTSThe mean (range) follow-up was 31 (12-74) months; the penis was 14-18 cm long and 11-15 cm in circumference. There was no partial or total flap necrosis; the donor site healed satisfactorily in 13 patients while in the remaining three there was moderate scarring. The patency of the urethra was good in all patients. Two urethrocutaneous fistulae developed; one closed spontaneously and the other was successfully treated with minor surgery. The function of the implanted penile prostheses was satisfactory in all patients. CONCLUSIONSThe MLD flap allows the creation of a neophallus of good size and with a good aesthetic appearance; it allows urethroplasty and safe implantation of a penile prosthesis, and it can also be used in children.
Background and Aims: The purpose of this prospective randomized study was to compare the early and midterm outcomes of aortic valve replacement (AVR) through upper ministernotomy with conventional AVR through median sternotomy.Methods: One hundred patients undergoing elective AVR were randomized into two groups: the M group (upper ministernotomy group, n = 50) and the C group (conventional sternotomy group, n = 50). The operative data, major adverse outcomes, and postoperative variables were compared between the two groups of patients. A cross-sectional follow-up was performed 24.9 ± 5.8 months after surgery.Results: The aortic cross-clamp time and cardiopulmonary bypass time were significantly longer in the M group. Similar incidences of major cardiac, neurologic and renal complications were recorded in both groups. Two patients (4%) in the C group developed wound infections. The length of ICU stay was similar in both groups.The patients in the M group had a shorter hospital stay compared with the patients in the C group (7.6 ± 2 days vs 9.3 ± 4.8 days; P = 0.022). Follow-up revealed that the time period needed to reach full recovery was significantly shorter in the ministernotomy group (1.7 ± 1.2 months vs 2.8 ± 1.6 months; P = 0.001). Morbidity and mortality data did not differ between the two groups.Conclusions: There was no difference in the major outcomes between the patients who underwent upper ministernotomy and those who underwent full sternotomy.The benefits of the minimally invasive approach were the shorter hospital stay and significantly faster recovery of patients after discharge from the hospital.
Cor triatriatum dexter is a rare congenital heart anomaly in which a membrane divides the right atrium into 2 chambers. We report the case of a 43-year-old C or triatriatum dexter (CTD) is a congenital anomaly in which the right atrium is divided into 2 parts by a membrane or fibromuscular band. This condition is extremely rare: in high-volume echocardiographic laboratories, the prevalence of CTD is less than 0.01%.1 Cor triatriatum dexter is often associated with other congenital anomalies, such as pulmonary artery stenosis or atresia, hypoplastic right ventricle, Ebstein anomaly, and atrial septal defect (ASD).2,3 Symptomatic patients with CTD and ASD are typically candidates for surgery, although successful percutaneous procedures have been reported. 4,5 We report our experience with a CTD patient when we attempted percutaneous treatment of the anomaly. Case ReportIn January 2013, a 43-year-old woman was examined at a regional hospital because of dyspnea on exertion (New York Heart Association [NYHA] functional class II-III). She had no signs of chronic heart failure. A continuous murmur was heard. A transthoracic echocardiogram (TTE) showed a 2.5 × 3.5-cm ASD (pulmonary-to-systemic flow ratio, 3:1) and a membrane that incompletely divided the right atrium into 2 chambers. Cor triatriatum dexter or a giant Eustachian valve was suspected, and the patient was referred to our institution.We used transesophageal echocardiography (TEE) and catheterization in an attempt to correct the anomaly percutaneously. The TEE showed that a membrane divided the right atrium into upper and lower chambers, thus conf irming a diagnosis of CTD (Fig. 1). Percutaneous balloon dilation disrupted the membrane and enlarged the communication between the chambers. This exposed the complete absence of an inferior rim on the patient's ASD: no tissue was available for anchoring an Amplatzer Septal Occluder (St. Jude Medical, Inc.; St. Paul, Minn). The risks of device malpositioning, device embolization, and residual shunting were high, so the patient was scheduled for surgery.Median sternotomy was performed and cardiopulmonary bypass was established. Access to the anomaly was gained through a right atriotomy. The large, fibrous congenital membrane, partially disrupted by the earlier percutaneous dilation, ran diagonally through the right atrium, reaching the interatrial septum on one end and the orifice of the inferior vena cava (IVC) on the other (Fig. 2A). A free margin and multiple small fenestrations enabled communication between the 2 atrial compartments. The ASD had a well-defined rim except in its inferior portion, where there was none. We resected the membrane, preserved its basal section for reconstructing the interatrial septum (Fig. 2B), and closed the residual ASD with use of a 3 × 2.5-cm pericardial
Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.
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