Guidelines for safely opening a previous sternotomy incision.

Operations through a previous sternotomy incision are associated with significant hazards, including cardiac injury, excessive hemorrhage during and after cardiopulmonary bypass, and postoperative sternal instability. A technique for safely opening previous sternotomy incisions has been developed at New York University Medical Center which has proved satisfactory in over 150 patients. It has been demonstrated repeatedly to be free of the serious and often lethal intraoperative and postoperative complications previously associated with this procedure.     

Total thyroidectomy replaces subtotal thyroidectomy as the preferred surgical treatment for Graves' disease

BACKGROUND: Total thyroidectomy is increasingly being adopted for patients requiring surgical treatment for Graves' disease based on a comparable surgical risk and the lack of recurrence, as well as the questionable ability of subtotal thyroidectomy to maintain euthyroidism. The purpose of the present paper was to evaluate its safety and efficiency. METHODS: Total thyroidectomy was adopted as part of the routine surgical treatment for Graves' disease from 2000. Patients who underwent subtotal thyroidectomy (STT) from 1995 to 1999 (n = 119) were compared with those who underwent total thyroidectomy (TT) from 2000 to 2003 (n = 98) with respect to immediate postoperative morbidity and long-term outcome. RESULTS: Fourteen (11.8%) and 22 patients (22.4%) required calcium supplement on discharge in the STT and TT groups, respectively (P < 0.05). One (0.8%) and three patients (3.1%) developed permanent hypocalcaemia, respectively. Transient recurrent laryngeal nerve palsy occurred in 9.2% (n = 11) and 5.1% (n = 5) of patients or 5.0% and 2.6% of nerves at risk after STT and TT, respectively. None of the patients had permanent nerve palsy. The estimated blood loss was less and hospital stay shorter after TT. During a mean follow up of 64 months, 86 patients (72.3%) in the STT group required thyroxine replacement and seven patients (5.9%) developed relapse. CONCLUSION: Subtotal thyroidectomy was associated with relapse as well as hypothyroidism in a significant proportion of patients during long-term follow up. Total thyroidectomy can be performed as safely as STT and should be recommended as the procedure of choice for patients requiring surgical treatment for Graves' disease.     

Partial versus full sternotomy for aortic valve replacement

Background. Recent trends suggest that smaller incisions reduce postoperative morbidity. This study tests the hypothesis that a partial upper sternotomy improves patient outcome for aortic valve replacement.

Methods. A group of 50 patients who underwent aortic valve surgery through a partial upper sternotomy (group I) were compared to 50 patients who underwent aortic valve replacement through a median sternotomy during the same time period (group II). The mean age (60 ± 2 versus 63 ± 2 years; mean ± SEM) and preoperative ejection fractions (53 ± 2 versus 54 ± 2) were similar. Operations were performed with central cannulation, and antegrade/retrograde blood cardioplegia.

Results. There was one death in each group. No differences were found in aortic occlusion time, mediastinal drainage, transfusion incidence, narcotic requirement, length of stay, or cost. The incidence of pleural and pericardial effusions was increased (18.4% versus 3.9%, p < 0.03), and the need for postoperative inotropic support was higher (38.7% versus 19.6%, p < 0.03) in the partial sternotomy group.

Conclusions. Aortic valve replacement can be performed through a partial sternotomy with results comparable to full sternotomy. The partial sternotomy offers a cosmetic benefit, but does not significantly reduce postoperative pain, length of stay, or cost.     

Partial sternotomy ("C" incision) as standard access for full range of adult cardiac operations.

OBJECTIVE: In our institute, partial sternotomy has been adopted for standard access in the full range of adult cardiac operations, including coronary artery bypass grafting. In this study, our clinical experience is reviewed. METHODS: Since April 1998, of 100 cardiac surgical patients, 64 underwent partial sternotomy, while 36 patients had the traditional full sternotomy because of high surgical risk factors or anatomical reasons. Most of the patients having minimal access had a "C" incision, that is, a left lower partial sternotomy. RESULTS: The procedures performed with the "C" incision were coronary artery bypass grafting, valve surgery, aortic root replacement, closure of atrial septal defect, and so on. There were two hospital deaths after partial sternotomy. Compared with full sternotomy patients, partial sternotomy patients had a shorter hospital stay, while their bypass times were longer. Their skin incisions were 11.7 cm on average. CONCLUSION: The "C" incision can provide satisfying results and can serve as the standard approach in the full range of cardiac operations.     

Coronary artery bypass grafting without full sternotomy

Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.     

Costovertebral angle as a novel tool for predicting the thoracic complication risk following percutaneous nephrolithotomy requiring supracostal access

IntroductionThe objective of this study was to determine whether the costovertebral angle (CVA) and other factors can predict the risk of thoracic complications following percutaneous nephrolithotomy (PCNL).MethodsThe data of patients who underwent prone PCNL with supracostal access at Suleyman Demirel University Hospital between January 2015 and December 2019 were retrospectively reviewed. Patients’ demographics information (age, sex, body mass index [BMI], stone size, and stone location), operative data (supracostal access site, renal puncture site, and laterality), and postoperative thoracic complications (pleural injury) were evaluated. The CVA was measured on preoperative posteroanterior chest X-ray images. The mean CVA of patients with and without thoracic complications was evaluated.ResultsA total of 89 patients (mean age 46.12±15.66 years; 59 men and 30 women) with supracostal access were included in the study. Thoracic complications occurred in 17 (19.1%) patients. Nine (52.9%) hemothorax cases, five (29.4%) pneumothorax cases, and three (17.7%) urinothorax cases were detected. There was a statistically significant difference in the complication rate compared to the percutaneous access site (10^th–11^th supracostal vs. 11^th–12^th supracostal, p=0.004). The mean CVA was significantly lower in patients with complications (45.47±3.59) than in those without complications (53.26±5.98) (p=0.000). No association was found (p>0.05) with age, sex, BMI, laterality, stone surface area, and access site among patients with and without thoracic complications.ConclusionsPreoperative CVA can be an effective tool in predicting the risk of postoperative thoracic complications.     

Transapical access for thoracic endograft delivery

The purpose of this paper is to describe the technique of transapical deployment of a thoracic endograft and to discuss the specifics of this access. The technique of endograft deployment through a transapical access is demonstrated in a patient with a symptomatic 14-cm aortic arch aneurysm. The 73-year-old patient, with concomitant chronic obstructive airway disease and cardiovascular disease, had been denied open surgery. Femoral artery access was deemed contraindicated because of a more distal concomitant type III thoracoabdominal aneurysm, borderline renal failure and heavily calcified iliac arteries. Bilateral iliac-subclavian debranching and thoracic endografting via a combined transapical and left subclavian access successfully excluded the thoracic aortic aneurysm. The patient died within 24 hours postoperatively due to a massive myocardial infarction. In conclusion, transapical access for thoracic endograft delivery is feasible. Combined with complex debranching procedures in a challenging aneurysmal anatomy, it carries a high risk for periprocedural complications.     

Risk factors for chronic thoracic pain after cardiac surgery via sternotomy

Objective: This study examines the influence of patient demographics and peri- and postoperative (<7 days) characteristics on the incidence of chronic thoracic pain 1 year after cardiac surgery. The impact of chronic thoracic pain on daily life is also documented. Methods: A prospective cohort study of 146 patients admitted to the intensive care unit after cardiac surgery via sternotomy was carried out. Pain scores (numeric rating scale 0–10) were recorded during the first 7 postoperative days. One year later, a questionnaire was used to evaluate the incidence in the 2 preceding weeks of chronic thoracic pain (numeric rating scale >0) associated with the primary surgery. Results: One year after surgery, 42 (35%) of the 120 responding patients reported chronic thoracic pain. Multivariate regression analysis of patient characteristics revealed that non-elective surgery, re-sternotomy, severe pain (numeric rating scale ≥4) on the third postoperative day, and female gender were all independent predictors of chronic thoracic pain. In addition, the chronic sufferers reported more sleep disturbances and more frequent use of analgesics than their cohorts. Conclusions: We have identified a number of factors correlated with persistent thoracic pain following cardiac surgery with sternotomy. Awareness of these predictors may be useful for further research concerning both the prevention and treatment of chronic thoracic pain, thereby potentially ameliorating the postoperative quality of life of a significant proportion of patients. Meanwhile, chronic thoracic pain should be discussed preoperatively with patients at risk so that they are truly informed about possible consequences of the surgery.     

Anterior thoracic corpectomy without sternotomy: A strategy for malignant disease of the upper thoracic spine

SummaryBackground With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal metastases. While no region of the spine is easily treated, the upper thoracic spine is perhaps the least accessible. Traditional approaches to this region involve either thoracotomy or at least limited sternotomy. The authors present an approach to anterior pathology of the upper thoracic spine that obviates the need for sternotomy.Methods Within the past two years, two patients with cervicothoracic metastases underwent anterior decompression and fusion without sternotomy. In both patients, the bodies of C7, T1, and T2 were removed. While both patients were prepared and draped for sternotomy, each required a neck dissection only. In both patients, left-sided incisions were made along the leading edge of the sternocleidomastoid. The platysma was divided with the overlying skin. With further dissection, the strap muscles were tagged and divided approximately one centimeter above their sternal attachments. The loose areolar tissue of the superior mediastinum was then bluntly dissected. Along the entire length of the incision, the vascular plane medial to the carotid sheath was developed to facilitate exposure of the anterior spine. A Farley-Thompson retractor system was then employed to retract and protect the superior mediastinal structures. With this exposure, corpectomies were carried out using a high speed drill. Fusion was accomplished through insertion of Steinmann pins into the adjacent intact bodies above and below. This was followed by application of methyl methacrylate. Both patients had immediate postoperative stability with preservation of spinal cord function. Both patients subsequently underwent removal of dorsally located tumor with posterior fusion.Conclusions The goal of cancer surgery is to provide for increased functional survival without undue morbidity. The authors feel that when possible, the pain of sternal and clavicular osteotomies should be avoided. The described approach works well in conjunction with a methyl methacrylate/Steinmann pin construct. Because of the intact sternum, the surgeon has a downward angle to access the superior endplate of T3. With adequate soft tissue dissection and retraction as described, however, T3 and perhaps even T4 are easily accessible. While this downward angle would likely not permit an anterior plating procedure, it lends itself nicely to Steinmann pin/methyl methacrylate fusion and spares the patient the pain and potential morbidity of sternotomy.     

Surgery using median sternotomy for diffuse aneurysmal disease of the thoracic aorta

We present our experience using an anterior approach for the replacement of an extensive aneurysm of the thoracic aorta. In recent years we have performed surgery on 20 patients by means of a median sternotomy for aneurysms of the ascending aorta, aortic arch, or descending thoracic aorta. In all but 1 of the patients, a procedure in the ascending aorta was also performed. In some patients a small anterior left thoracotomy at the 4th intercostal space was required to allow the replacement of the aorta as for the diaphragm. Antegrade selective cerebral perfusion (ASCP) according to Kazui's technique was used as a brain protection method. All procedures were performed successfully and the aneurysm was completely resected. No neurologic complications or other major complications occurred. We believe that the anterior approach for extensive thoracic aorta replacement is feasible, allows the use of ASCP, and has shown encouraging results.     

经胸入路腔镜甲状腺微小乳头状癌切除术体会

目的 探讨影响腔镜下甲状腺微小乳头状癌手术成功的因素.方法 对11例甲状腺微小乳头状癌患者采用腔镜下行患侧甲状腺全切除术加峡部切除术,并对全组病例随访1年余.结果 腔镜下完成手术10例,中转开放手术1例,2例出现暂时性喉返神经麻痹.手术时间60～100 min,平均85 min,术中出血10～40 ml,术后平均住院时间为5 d.结论 腔镜下甲状腺微小乳头状癌手术具有手术彻底和美容效果,是一种安全、可行的术式.     

Completion thyroidectomy for malignancy after initial minimal access thyroid surgery

BACKGROUND: Minimal access thyroid surgery (MATS), carried out through a lateral 2.5-cm incision, provides excellent clinical and cosmetic outcomes when carried out for small (<3 cm), single nodules. However, if the final pathology shows thyroid malignancy and a completion thyroidectomy is required, the small lateral incision requires conversion to a standard collar incision and the second operation must be carried out in the presence of previous lateral dissection. The aim of this study is to determine if there is any demonstrable disadvantage to completion thyroidectomy for malignancy after MATS when compared with the same procedure after conventional hemithyroidectomy. METHODS: This retrospective cohort study examined all patients undergoing completion thyroidectomy for malignancy in the University of Sydney Endocrine Surgical Unit from January 2002 to January 2005. Outcome measures were complication rates, final scar length and patient's self-assessment of scar appearance. RESULTS: A total of 106 patients underwent MATS during the study period, 11 of whom required completion thyroidectomy for malignancy. During the same period, 42 patients required completion thyroidectomy for malignancy after previous conventional hemithyroidectomy. There was no difference in complication rates between the two groups. The two complications in the study consisted of one case of flap oedema (control) and one case of keloid scar (MATS). Mean final incision length, scar appearance and patient's satisfaction with scar did not differ between the two groups. CONCLUSION: There is no demonstrable disadvantage when completion thyroidectomy for malignancy is required after MATS.     

胸腔镜辅助下小切口在胸椎前路手术的临床应用

目的探讨胸腔镜辅助下小切口行胸椎前路手术的可行性. 方法 2001年10月～2002年10月,我院在胸腔镜辅助下小切口行胸椎前路手术14例.其中6例胸椎转移瘤行病变椎体切除、钢板骨水泥椎体重建及前路针棒内固定;4例胸椎结核行病灶清除、植骨及前路钉棒内固定;2例胸椎间盘突出症行髓核摘除、椎间植骨融合;2例胸椎椎体骨折合并脱位行脱位椎体复位、椎管减压、椎体间植骨及前路钉棒内固定. 结果术后影像学显示病灶清除彻底,内固定效果确切.14例术后随访 4～12个月,14例胸背痛完全消失,13例脊髓压迫症中除1例转移瘤无改善外,其余12例肌力术前A～D级,术后恢复至C～E级. 结论胸腔镜辅助下小切口行胸椎前路手术方法可行,近期疗效满意.     

Reversed-J inferior versus full median sternotomy: which is better for awake coronary bypass surgery

BACKGROUND: The aim of this study was to ascertain whether the approach with a less invasive reversed-J inferior sternotomy could improve intraoperative patient compliance and postoperative recovery than the standard median sternotomy. METHODS: Seventeen patients underwent elective single coronary artery bypass graft operation under high thoracic epidural anesthesia without endotracheal intubation. The reversed-J sternotomy was performed in 10 patients (Group A) and full sternotomy in 7 patients (Group B). The technical and surgical difficulties, pulmonary functions (by spirometric tests) and hospital stay were assessed. RESULTS: Through the reversed-J sternotomy coronary revascularization was accomplished without any additional technical difficulties and with a good exposure of both the left anterior descending artery and the left internal thoracic artery. No conversion to standard sternotomy and no intubation were observed. Additional doses of local anesthetic at jugular notch was not required in Group A. Pleura was opened more in Group B (57% vs. 20%; p = 0.14). Oxygen saturation was better in Group A during the surgical procedure (98.8 +/- 0.7% vs. 97.1 +/- 2.1%; p = 0.033), however, intraoperative PaCO2 was similar in both the groups. The patients in Group A were discharged from the hospital earlier (3.2 +/- 1.5 vs. 7.3 +/- 3.5 days; p = 0.004). CONCLUSIONS: Less invasive approach to coronary artery bypass graft operations is possible through combination of the high thoracic epidural anesthesia and a reversed-J sternotomy. This technique is less traumatic for patient and provides practical better oxygenation and shorter hospital stay.     

Management of arterial access for thoracic endovascular aortic repair

Problems associated with arterial access can sometimes occur in elder patients with arteriosclerosis. This study examined the management of patients with restricted arterial access using thoracic endovascular aortic repair (TEVAR). Thirty-four consecutive patients underwent TEVAR at our institution. TEVAR was performed using a Gore TAG device (n = 20), Talent thoracic stent graft (n = 10), and a homemade endoprosthesis device (n = 3). The sizes of the applied sheath introducer or delivery catheter were 20 Fr (n = 1), 22 Fr (n = 12), 24 Fr (n = 17), and 25 Fr (n = 4). Although the procedure was completed in all cases, additional procedures for catheter preparation were required in 8 patients (23.5%). Percutaneous transluminal angioplasty (PTA) with stents placed in the iliac artery (n = 3) or the installation of a bypass conduit (n = 4) was also carried out. For the remaining cases, in which advancement of the TAG sheath introducer to the appropriate position was not possible, the endoprosthesis was deployed without the sheath introducer. Two cases required PTA after the procedure due to an injury of the iliac artery. Although some additional procedures may be required, TEVAR can be performed in patients with problems of arterial access.     

Resection of advanced thoracic malignancies requiring cardiopulmonary bypass.

OBJECTIVES: Patients with malignancies involving cardiac structures have limited therapeutic options and significant risk of mortality. The decision to offer radical palliative or curative resection must be made only after consideration of the substantial surgical risks. The purpose of this retrospective study was to determine the feasibility and benefits of resection with cardiopulmonary bypass (CPB) of metastatic or non-cardiac primary malignancies extending directly into or metastasizing to the heart in select patients. Our results were examined to assess the risks and benefits of such radical therapy. METHODS: We retrospectively reviewed patient charts and identified all patients with malignancies involving the cardiac chamber or great vessels (excluding renal carcinomas with caval extension) or with substantial cardiac compression who had undergone resection with CPB at The University of Texas M.D. Anderson Cancer Center between January 1995 and July 2000. We evaluated demographic data, symptomatology, tumor characteristics, and outcomes. RESULTS: Nineteen patients (six males and 13 females; median age of patients, 47 years; age range, 17-67 years) were included in the study. Eleven patients underwent surgery with curative intent, and eight underwent surgery with palliative intent. Seventeen patients had tumors that required CPB because their tumors directly involved the heart and/or great vessels (nine sarcomas, seven epithelial carcinomas, and one unclassified), and two patients (both with sarcomas) required CPB to relieve tumor tamponade. The technique included CPB (n=5), CPB with diastolic arrest (n=12), and CPB with hypothermic circulatory arrest (n=2). Five patients underwent concomitant pneumonectomy, and three underwent lobectomy. Two patients (11%) died in the hospital after resection with palliative intent. Of the 11 patients who underwent resection with curative intent, ten (91%) had complete resections. The median time in the intensive care unit was 5.3 days (range, 0-37 days) and the median length of hospital stay was 17.2 days (range, 0-107 days). Major complications occurred in 11 patients (58%); the most common major complications were pneumonia (n=7 patients), mediastinal hematoma (n=4 patients), and acute respiratory distress syndrome (n=2 patients). The median follow-up duration was 27 months. The overall 1- and 2-year survival rates were 65 and 45%, respectively. CONCLUSIONS: Extensive thoracic tumors involving cardiac structures can be resected with acceptable risk. When resection was performed with curative intent, excellent 1- and 2-year cumulative survival rates were achieved. Although resection with palliative intent was associated with greater mortality rates, some patients survived for 1 and 2 years. The use of CPB in selected patients with thoracic malignancies should be considered, especially when complete resection can be achieved.     

Partial median sternotomy as a minimal access for the closure of subarterial ventricular septal defect

Background: Minimally invasive techniques in congenital heart surgery have evolved steadily over the past few years, but documentation in the literature is rare. The majority of reported techniques involve thoracoscopic approach and partial sternotomy. We have employed a lower partial sternotomy as a minimal-access procedure for the closure of subarterial ventricular septal defect, for situation where this approach would be unsuitable for adequate exposure of the pulmonary artery. The purpose of this study is to demonstrate the feasibility and safety of this technique and report its superior cosmetic result. Subjects and Methods: Beginning in 1997, we began approaching the closure of subarterial ventricular septal defect through a lower sternal split incision using a 6 to 10 cm skin opening, associated with a reversed L incision at the left second intercostal space. A total of consecutive 12 patients (6 male and 6 female) have been operated on using this approach. The patients ranged in age from 6 to 21 years (mean, 12.8 ± 5.0 years). The straight cannula with stylet was used for aortic cannulation. Results: There was no mortality or morbidity, except for late pericardial effusion in 4 cases. The durations of cardiopulmonary bypass and aortic cross-clamping ranged from 94 to 206 (mean, 131 ±33) minutes and from 40 to 122 (mean, 70 ± 26) minutes, respectively. Ten of 12 patients were extubated in the operating room, and no patient required blood transfusion. The postoperative hospital stay ranged from 8 to 21 (mean, 13.4 ± 4.2) days. No patient developed deterioration of aortic regurgitation or residual ventricular septal defect. Conclusions: Our experience demonstrates that the lower partial sternotomy for the closure of subarterial ventricular septal defect is technically feasible and can be used with excellent cosmetic results and safety. Although experience is limited and follow-up is relatively short, this less invasive surgical technique may become a beneficial option for the management of subarterial ventricular septal defect.     

Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery

BACKGROUND: The National Emphysema Treatment Trial, a randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema, included randomized and nonrandomized comparisons of the median sternotomy and video-assisted thoracoscopic approaches for lung volume reduction surgery. METHODS: Lung volume reduction surgery was performed by median sternotomy only at 8 centers and video-assisted thoracoscopy only at 3 centers; 6 centers randomized the approach to lung volume reduction surgery. Mortality, morbidity, functional status, and costs were assessed. RESULTS: In the nonrandomized comparison, 359 patients received lung volume reduction surgery by median sternotomy, and 152 patients received lung volume reduction surgery by video-assisted thoracoscopy. The 90-day mortality was 5.9% for median sternotomy and 4.6% for video-assisted thoracoscopy (P =.67). Overall mortality was 0.08 deaths per person-year for median sternotomy and 0.10 deaths per person-year for video-assisted thoracoscopy (video-assisted thoracoscopy-median sternotomy risk ratio, 1.18; P =.42). Complication rates were low and not statistically different for the 2 approaches. The median hospital length of stay was longer for median sternotomy than for video-assisted thoracoscopy (10 vs 9 days; P =.01). By 30 days after surgery, 70.5% of median sternotomy patients and 80.9% of video-assisted thoracoscopy patients were living independently (P =.02). Functional outcomes were similar for median sternotomy and video-assisted thoracoscopy at 12 and 24 months. Costs for the operation and the associated hospital stay and costs in the 6 months after surgery were both less for video-assisted thoracoscopy than for median sternotomy (P <.01 in both cases). Similar results were noted for the randomized comparison. CONCLUSIONS: Morbidity and mortality were comparable after lung volume reduction surgery by video-assisted thoracoscopy or median sternotomy, as were functional results. The video-assisted thoracoscopic approach to lung volume reduction surgery allowed earlier recovery at a lower cost than median sternotomy.