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Use of Colostomy Bags for Chest Tube Drainage
456
CORRESPONDENCE
ring, 180 degrees apart. The rotational force, however, should not be excessive or sudden. It must be gentle and gradual.
Robert L. Berger, M D Karl 1. Karlson, M D Mian M . Ashraf, M D Department of Cardiothoracic Surgery New England Deaconess Hospital Harvard Medical School 135 Francis Street, Boston, M A 02215
Use of Colostomy Bags for Chest Tube Drainage To the Editor: We read with interest the article by Velanovich and Adams [ l ] on the use of colostomy bags for chest tube drainage. We have been using these bags for the last 3 years and we fully agree that such use reduces the hospital stay and increases the mobility of patients. We want to point out that it is important for the colostomy bag to .have an opening at the top so that the air can escape; otherwise, a patient with bronchial air leak might develop tension pneumothorax. This is an important fact that was not emphasized in the article.
Fig 1 . Transesophageal echocardiographic scanning (longitudinal view) showing a left atrial mass (asterisk) close to the atrial septum and a few centimeters above the mitral valve (MV).
I
Ajay Kaul, MCh Anil Patwardhan, M S Arun Chaukar, M S Department of Cardiothoracic Surgery L.T.M. Medical College 6 Sion Hospital, Sion, Bombay 400 022, India
Reference 1. Velanovich V, Adams CW. The use of colostomy bags for chest tube drainage. Ann Thorac Surg 1988;46:697-8.
Reply To the Editor: We agree that when using a closed system such as a colostomy bag for drainage of the pleural space, a bronchopleural air leak will lead to a pneumothorax. An opening at the top of the cotpstomy bag may remedy this problem. We have never had the opportunity to treat a patient with a bronchopleural air leak with the colostomy bag drainage system we have described. We feel that the indications for the colostomy system in such a patient are limited.
Vic Velanovich, M D Carl W . Adams, M D Department of Surgery Letterman Army Medical Center Presidio of Sun Francisco, C A 94129-6700
Value of Transesophageal Echocardiography During Open Heart Operation To the Editor: The use of two-dimensional transesophageal echocardiography during open heart procedures is becoming increasingly popular [l]. We report a patient in whom two-dimensional transesoph-
ageal echocardiography disclosed a thrombus in the left atrium after a mitral-aortic valve operation, allowing the prevention 01 a possible life-threatening systemic embolism. A 62-year-old man with mitral and aortic stenosis was referred to our unit for surgical treatment. At operation, performed in January 1989, open mitral commissurotomy with splitting of the papillary muscles and aortic valve replacement with a 25-mm Pericarbon bioprosthesis (Sorin Biomedica, Saluggia, Italy) were performed. Direct inspection failed to demonstrate any thrombus in either the left atrium or the left atrial appendage. At the end of the procedure air bubbles were removed from the heart using standard techniques, which included cardiac massage and vigorous inflation of the lungs. After release of the aortic cross-clamp the heart resumed spontaneous activity but was kept unloaded during completion of rewarming. At this stage two-dimensional transesophageal echocardiography, employed with the aim of evaluating the success of mitral valve repair, showed the unexpected presence of a mobile mass in the left atrium, which was interpreted as a thrombus (Fig 1). Rewarming was then interrupted, the aorta was cross-clamped, and the heart was again arrested with crystalloid cardioplegia. The right atrium was opened and the left atrium was entered through the fossa ovalis. By this approach a free floating thrombus, most likely previously dislodged into a pulmonary vein, was noted and removed. The procedure was then completed uneventfully and the patient was discharged on postoperative day 8 in good condition. The intraoperative use of two-dimensional transesophageal echocardiography has proved effective in the evaluation of left ventricular contractility after coronary bypass operations, in the assessment of adequacy of valve repair techniques, and in the detection of intracardiac air bubbles before discontinuation of cardiopulmonary bypass [1-3]. We report here a patient in whom the presence of a thrombus in the left atrium, which had escaped initial intracardiac inspection and would have most likely resulted in systemic embolization, was diagnosed by twodimensional transesophageal echocardiographic monitoring allowing an uncomplicated outcome. We believe that this experience supports the current trend of expanded use of two-
CORRESPONDENCE
ring, 180 degrees apart. The rotational force, however, should not be excessive or sudden. It must be gentle and gradual.
Robert L. Berger, M D Karl 1. Karlson, M D Mian M . Ashraf, M D Department of Cardiothoracic Surgery New England Deaconess Hospital Harvard Medical School 135 Francis Street, Boston, M A 02215
Use of Colostomy Bags for Chest Tube Drainage To the Editor: We read with interest the article by Velanovich and Adams [ l ] on the use of colostomy bags for chest tube drainage. We have been using these bags for the last 3 years and we fully agree that such use reduces the hospital stay and increases the mobility of patients. We want to point out that it is important for the colostomy bag to .have an opening at the top so that the air can escape; otherwise, a patient with bronchial air leak might develop tension pneumothorax. This is an important fact that was not emphasized in the article.
Fig 1 . Transesophageal echocardiographic scanning (longitudinal view) showing a left atrial mass (asterisk) close to the atrial septum and a few centimeters above the mitral valve (MV).
I
Ajay Kaul, MCh Anil Patwardhan, M S Arun Chaukar, M S Department of Cardiothoracic Surgery L.T.M. Medical College 6 Sion Hospital, Sion, Bombay 400 022, India
Reference 1. Velanovich V, Adams CW. The use of colostomy bags for chest tube drainage. Ann Thorac Surg 1988;46:697-8.
Reply To the Editor: We agree that when using a closed system such as a colostomy bag for drainage of the pleural space, a bronchopleural air leak will lead to a pneumothorax. An opening at the top of the cotpstomy bag may remedy this problem. We have never had the opportunity to treat a patient with a bronchopleural air leak with the colostomy bag drainage system we have described. We feel that the indications for the colostomy system in such a patient are limited.
Vic Velanovich, M D Carl W . Adams, M D Department of Surgery Letterman Army Medical Center Presidio of Sun Francisco, C A 94129-6700
Value of Transesophageal Echocardiography During Open Heart Operation To the Editor: The use of two-dimensional transesophageal echocardiography during open heart procedures is becoming increasingly popular [l]. We report a patient in whom two-dimensional transesoph-
ageal echocardiography disclosed a thrombus in the left atrium after a mitral-aortic valve operation, allowing the prevention 01 a possible life-threatening systemic embolism. A 62-year-old man with mitral and aortic stenosis was referred to our unit for surgical treatment. At operation, performed in January 1989, open mitral commissurotomy with splitting of the papillary muscles and aortic valve replacement with a 25-mm Pericarbon bioprosthesis (Sorin Biomedica, Saluggia, Italy) were performed. Direct inspection failed to demonstrate any thrombus in either the left atrium or the left atrial appendage. At the end of the procedure air bubbles were removed from the heart using standard techniques, which included cardiac massage and vigorous inflation of the lungs. After release of the aortic cross-clamp the heart resumed spontaneous activity but was kept unloaded during completion of rewarming. At this stage two-dimensional transesophageal echocardiography, employed with the aim of evaluating the success of mitral valve repair, showed the unexpected presence of a mobile mass in the left atrium, which was interpreted as a thrombus (Fig 1). Rewarming was then interrupted, the aorta was cross-clamped, and the heart was again arrested with crystalloid cardioplegia. The right atrium was opened and the left atrium was entered through the fossa ovalis. By this approach a free floating thrombus, most likely previously dislodged into a pulmonary vein, was noted and removed. The procedure was then completed uneventfully and the patient was discharged on postoperative day 8 in good condition. The intraoperative use of two-dimensional transesophageal echocardiography has proved effective in the evaluation of left ventricular contractility after coronary bypass operations, in the assessment of adequacy of valve repair techniques, and in the detection of intracardiac air bubbles before discontinuation of cardiopulmonary bypass [1-3]. We report here a patient in whom the presence of a thrombus in the left atrium, which had escaped initial intracardiac inspection and would have most likely resulted in systemic embolization, was diagnosed by twodimensional transesophageal echocardiographic monitoring allowing an uncomplicated outcome. We believe that this experience supports the current trend of expanded use of two-