Use of the lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap for treatment of antecubital burn contractures

We describe a lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap for coverage of the antecubital fossa after burn scar release. In this study we describe raising and insetting the flap and reported our clinical results and observations.Antecubital contracture release was carried out in six patients, and the lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap was raised based on the anterolateral cutaneous perforator of the appropriate intercostal artery. The defects were repaired with this flap.All the flaps survived and antecubital contractures were repaired successfully. No recurrent contracture occurred in any of the patients at a mean of 15.3 months.The lateral intercostal artery perforator-based pedicled reverse thoraco-abdominal flap can be used effectively for repair of antecubital tissue defects as an alternative to other reconstructive methods.     

Intercostal nerve block with thoracoabdominal and flank incisions

A double-blind study was done in 90 patients undergoing a rib-resecting thoraco-abdominal incision for testicular cancer or a flank incision for renal surgery to determine the effect of intraoperative intercostal nerve block with bupivacaine hydrochloride on postoperative pain and complications, day of ambulation, and day of oral fluid intake. In the patients treated with bupivacaine, we found a significant reduction in the amount of postoperative analgesia required, but no difference in the day of ambulation or fluid intake. Ten of 45 patients given a placebo nerve block experienced postoperative atelectasis, whereas only 4 of 45 patients in the treated group experienced this complication. We believe that intercostal nerve block is a valuable postoperative adjuvant in patients undergoing flank surgery to reduce the postoperative analgesic requirements and incidence of atelectasis.     

A new suture technique for reconstruction of intercostal arteries during thoracoabdominal aortic aneurysmal surgery.

Reconstruction of several intercostal arteries is inevitable in surgical treatment of thoraco-abdominal aortic aneurysm. A Dacron inverted-Y shaped graft was fashioned by cutting one of two graft legs and making an elliptical patch, like a cobra-head. Once the elliptical patch was sutured to the orifices of the intercostal arteries (usually from T9 to T12) with running sutures, selective intercostal arterial perfusion was initiated. After completion of aneurysmectomy, the distal end of the elliptical patch graft was sutured to the main tube graft. This method is easier and faster and results in a decreased incidence of spinal cord injury.     

Thoracic aneurysm expansion secondary to collateral supplies via thyrocervical trunk and intercostal arteries in a patient after thromboexclusion.

A case of thoraco-abdominal aortic aneurysm complicated after permanent clamping of the descending aorta (thromboexclusion) is reported. Angiographic and operative findings were: (1) a pseudo-aneurysm right at the distal anastomosis of previous intrathoracic bypass for pseudo-coarctation of the aorta filled by left ninth intercostal artery, which was supplied by the left internal thoracic artery; and (2) the cervical and thoracic spinal cord were supplied by the left vertebral artery and the mediastinal branch of the left thyrocervical trunk. This rare cause of a thoraco-abdominal aortic aneurysm and the significance of the subclavian artery as a source of spinal cord blood supply are discussed.     

Prevention of paraplegia secondary to operations on the aorta

Prevention of paraplegia during operations on the aorta requires knowledge of the blood supply to the spinal cord. The great radicular artery of Adamkiewicz (RAD) plays a major role in the supply to the anterior spinal artery which nourishes the anterior two-thirds of the cord. The RAD usually arises from an intercostal artery between T9-T12 but may arise higher or in 10% of patients from a lumbar artery. Temporary interruption of flow by crossclamping, hypotension, or permanent interruption of the RAD are factors in the etiology of paraplegia. In resection of descending thoracic aortic aneurysms, the thoracic aorta should not be crossclamped without an external bypass. The bypass should be nonthrombogenic to avoid necessity for anticoagulation and attendant hemorrhagic problems. Bypass flow is ideally controlled by a pump with continuous monitoring of the proximal and distal pressures to provide normal distal flow to the cord. As many intercostal and high lumbar arteries as possible should be preserved by retaining the distal posterior wall of the aneurysm. Preoperative selective catheterization of the distal thoracic intercostal or proximal lumbar vessels can delineate critical supply to the cord and should become part of the routine workup of patients being considered for surgery of the distal thoracic and thoraco-abdominal aorta. Knowledge of the location of the RAD may permit its avoidance or reinsertion into a graft. Avoidance of the RAD may be particularly applicable with infrarenal aneurysms when a large lumbar artery is seen just above or below a renal artery. Here, avoidance of all but brief suprarenal clamping and resection of the aneurysm below the feeding RAD may help to avoid paraplegia.     

Incisional Intercostal Hernia With Prolapse of the Colon After Right Partial Nephrectomy

A 75-year-old woman with a history of myocardial infarction, gallstones, and right renal cancer was referred to our department because of right flank pain. She had a surgical scar on the right abdomen between the 10th and 11th ribs; computed tomography demonstrated intercostal herniation of the colon. Recognizing the possibility of adhesions of the hernia and colon, we used a median skin incision and patched a polyester mesh coated with absorbent collagen. The patient had an uneventful postoperative course, with no pain for 6 months postoperatively. Transdiaphragmatic intercostal hernias with abdominal contents commonly develop after trauma or thoracic surgery. Incisional intercostal hernias seldom develop after nephrectomy; the present case is only the fourth report. We conjecture that a costochondral incision can induce subluxation of the costotransverse joint, intercostal nerve injury, and atrophy of the intercostal and abdominal oblique muscles. Surgeons must therefore recognize the potential, albeit rare, for intercostal hernia after nephrectomy.     

Experimental development of an endovascular graft for thoraco-abdominal aortic aneurysm repair

AIM: Current treatment of thoraco-abdominal aortic aneurysms is surgical. Despite significant advances in surgical technique and anesthetic management, significant morbidity and mortality remain associated with their repair. In compliance with principles of reducing postoperative morbidity, we developed a thoraco-abdominal endovascular graft in experimental models of type III and type IV thoraco-abdominal aortic aneurysm. This device had to preserve the vascularization of the visceral arteries while ensuring full aneurysmal exclusion. METHODS: Six implantations of the endovascular graft were performed. This graft was a modular system, made of: 1) a custom made main body containing 4 prosthetic visceral branches, 2) 4 self-expandable stent-grafts connecting prosthetic visceral branches with visceral arteries, 3) a custom made tubular endovascular graft connecting the main body with one of the iliac arteries. RESULTS: On angiographic controls, full aneurysmal exclusion was achieved while maintaining visceral artery perfusion. At the end of each procedure, the experimental model was opened. Macroscopic examination showed harmonious thoraco-abdominal endovascular graft deployments, without abnormal component constraint or kinking. There was no discordance between macroscopic and angiographic RESULTS: CONCLUSIONS: Our experimental work led to the development of a thoraco-abdominal endovascular graft, demonstrating feasibility of thoraco-abdominal aneurysm endoluminal treatment on an in vitro model close to the anatomical conditions observed in human pathology.     

Multilayer stents in the treatment of thoraco-abdominal residual type B dissection

Multilayer stents are already being used for the treatment of peripheral aneurysms. In France, they are currently under evaluation in the treatment of thoraco-abdominal aneurysms. We have used multilayer stents to treat aneurysmal evolution of thoraco-abdominal residual type B dissection. Third month computed tomography (CT)-scan showed a false channel no longer patent. Multilayer stents are promising but it is too soon to draw conclusions on the use of this device in the treatment of patent false channels.     

Can vascularization improve the surgical outcome of the intercostal nerve transfer for traumatic brachial plexus palsy? A clinical comparison of vascularized and non-vascularized methods.

It is very difficult to design a well-controlled comparative study for clarifying the value of vascularized nerve grafting in clinical cases. In order to understand whether or not the vascularizing procedure has any clinical value in nerve transfer and in nerve grafting, we compared non-vascularized with vascularized intercostal nerve transfer in patients with brachial plexus injury. Factors that were likely to affect the results were controlled. We found there was no significant difference in the functional outcome and no difference in the regenerating rate of the nerves between nonvascularized and vascularized intercostal nerve transfer. We concluded that the vascularizing procedure had little clinical value not only in intercostal nerve transfer, but also in nerve grafting irrespective of the length of the gap, when the recipient bed had normal vascularity.     

Spinal cord ischemia may be reduced via a novel technique of intercostal artery revascularization during open thoracoabdominal aneurysm repair

OBJECTIVE: To describe a novel technique for maximal reimplantation of intercostal arteries during thoracoabdominal aortic aneurysm repair. METHODS: Eight patients underwent thoracoabdominal aortic aneurysm (TAAA) repair with this new technique from 2005 to 2006. Follow-up ranged from 6 to 14 months. All patients had a previous type B dissection with subsequent aneurysmal degeneration into an extent I TAAA. Aneurysm repair was performed through a thoracoabdominal incision and circulatory arrest in seven and left atrial-left femoral (LA-FA) bypass in one. The grafts extended from the distal arch at the subclavian artery to the visceral and renal arteries. An 8 mm graft was then extended from the proximal to the distal graft with a spatulation of the graft allowing a side-to-side anastomosis of the graft to the posterior aortic wall incorporating multiple pairs of intercostal arteries. Intraoperative electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) were monitored during each operation. RESULTS: All patients were ambulatory at the time of admission. One patient had suffered a previous spinal cord infarction from the original dissection and had residual unilateral leg weakness prior to the TAAA repair. There was an average of seven pairs of patent intercostal arteries upon opening the aorta. We reimplanted an average of five pairs of vessels. There were no perioperative complications. No patients sustained transient or permanent paraplegia in the postoperative or follow-up period. The one patient with preoperative leg weakness had reported subjective increased strength in the affected leg after the operation. In four cases, normalization of SSEP waveforms did not occur until after reimplantation of the intercostal arteries despite full return of EEG waveforms, restoration of lower extremity perfusion, and rewarming of the patient. Follow-up CT scan angiogram demonstrated that all reconstructions were patent through the follow-up period. CONCLUSIONS: Paraplegia is an extremely morbid complication associated with TAAA repair. We describe a technique that allows reimplantation of almost all intercostal arteries as one patch circumventing the need for selective reimplantation. Furthermore, our technique ensures continued patency of this patch graft as the outflow resistance is decreased by creating a continuous flow loop. Although this is a small case series, we had no incidence of acute or delayed paraplegia in this high risk group. Our technique of intercostal reimplantation is applicable to all open TAAA repair at high-risk for paraplegia and may be an important adjunct in preventing spinal cord ischemia.     

A centrifugal pump for graft replacement of the descending thoracic or thoraco-abdominal aorta

Between January 1987, and December 1988, 14 cases of descending thoracic or thoraco-abdominal aortic aneurysm underwent operation using a prosthetic graft replacement. In order to avoid hypoperfusion to distal organs and proximal hypertension during aortic cross-clamping, two different adjuncts were used and the effectiveness of those methods were compared according to the results of surgery. Seven patients were treated with a temporary shunt of heparin-bonded tube from the left axillary artery to left femoral artery, or else Dacron vascular prosthesis from right axillary artery to right femoral artery (Group I). In Group II (seven patients), left heart bypass was performed, using a centrifugal pump from the left atrium to the left femoral artery with minimal heparinization. In Group I, there were two hospital deaths, due to respiratory and hepatic failure respectively, and paraplegia has occurred in one case. In Group II, there was no death during a post-operative observation period of 5-15 months, and there was no case of paraplegia. We think that temporary left heart bypass with a centrifugal pump seems to be the most useful method today for graft replacement of the descending thoracic or thoraco-abdominal aorta.     

Intercostal nerve block with 5% tetracaine for chronic pain syndromes

Treating chronic pain syndromes is always challenging. We describe an effective use of an intercostal nerve block using 5% tetracaine in three patients with postherpetic intercostal neuralgia or postoperative intercostal neuralgia.     

A case of racemose hemangioma of the right bronchial artery and intercostal to pulmonary arterial anastomosis

We reported a case of racemose hemangioma of the bronchial artery and intercostal to pulmonary arterial anastomosis. A 67-year-old woman was admitted because of repeated hemoptysis. Bronchoscopic examination revealed a torous lesion of the right B⁷ bronchus. Intercostal angiography demonstrated communications between right dilated, meandered intercostal arteries and right pulmonary artery. Bronchial angiography showed dilatation and convolution of the right bronchial artery. Angiographic embolization of the right bronchial artery and the right intercostal artery was underwent. There was no recurrence of hemoptysis one year after the embolization procedure. We think that angiographic embolization is an effective method of treatment of hemoptysis due to racemose hemangioma of the bronchial artery and intercostal to pulmonary arterial anastomosis.     

Congenital Intercostal Lung Herniation Combined with an Unusual Morgagni's Hernia

A 70-year-old male visited urgent care due to coughing for 1 month and left chest pain. He had no history of trauma. The initial chest computed tomography (CT) showed the 7th left intercostal lung herniation. A follow-up CT showed an intercostal lung herniation combined with a bowl herniation, which had developed due to a Morgagni's hernia. An emergency operation was performed due to the incarceration of the bowl and lung. The primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined. We concluded that the defect of the diaphragm and the intercostal muscle was a congenital lesion, and the recurrent coughing was the aggravating factor of herniation.     

Totally laparoscopic aortohepatic bypass for aortic debranching during endovascular thoracoabdominal aneurysm repair.

INTRODUCTION: Endovascular grafting of the aorta is gaining widespread acceptance for treating aortic aneurysms. Para-renal aneurysms or thoraco-abdominal aneurysms may be a relative contra-indication for endovascular aneurysm repair (EVAR) unless visceral vessels can be debranched. REPORT: We describe a case of thoraco-abdominal aneurysm extending from the descending thoracic aorta to the level of coeliac artery. A totally laparoscopic retrograde aorto-hepatic bypass was performed in conjunction with endograft exclusion of the aneurysm and coverage of the coeliac artery ostium. DISCUSSION: Laparoscopic debranching of visceral vessels extends the indications of EVAR.     

Lobar torsion following thoraco-abdominal oesophagogastrectomy

Following thoraco-abdominal oesophagogastrectomy for an adenocarcinoma of the lower oesophagus, an 81-year-old female with no pre-existing respiratory disease could not be weaned from mechanical ventilation. Right upper and middle lobe torsion were found at thoracotomy on the 14th postoperative day. Both lobes were resected. The patient was discharged from hospital after several postoperative complications. Pulmonary torsion is a rare, potentially life-threatening complication of thoraco-abdominal oesophagogastrectomy. Differentiation from the more common postoesophagectomy pulmonary complications can be difficult. Early post-thoracotomy lung opacification, in the absence of the expected degree of hypoxaemia, should trigger a suspicion of pulmonary torsion.     

切除第11肋的经膈肌胸、腹膜外胸腹联合切口治疗胸腰段脊椎病变

目的介绍一种改良的经膈肌胸、腹膜外胸腹联合切口治疗胸腰段脊柱病变。方法回顾性分析88例胸腰段病变的患者,均采用切除第11肋的经膈肌胸、腹膜外胸腹联合切口,直接暴露胸腰段椎体,施行各类脊柱手术。结果本组手术暴露时间为30~50 m in,病灶清除彻底,螺钉位置理想。术后发生气胸1例,乳糜液漏1例。62例平均随访23个月,无钢板断裂、植骨不融合、脊柱后凸畸形等并发症发生。结论该手术切口对组织损伤小,手术视野好,术后并发症少,适用于胸腰段脊椎病变的手术。     

Intercostal neuroma as a source of pain after aesthetic and reconstructive breast implant surgery

The development of persistent post-operative pain after implant placement for aesthetic or reconstructive breast surgery can lead to significant patient morbidity. Although there are many etiologies for post-operative pain, the diagnosis of an intercostal neuroma is important as this can be treated surgically. We describe three cases of an intercostal neuroma in patients with breast implants. A Tinel's sign can be elicited along the lateral chest wall and a local anesthetic block temporarily alleviates this pain. Surgical management with identification and clipping of the intercostal neuroma and burying into the underlying muscle significantly decreases post-operative pain long term. In patients with persistent pain after breast implant placement, plastic surgeons must be aware of this treatable cause of pain.     

Spontaneous transdiaphragmatic intercostal hernia: a rare clinical entity

The herniation of abdominal contents through a diaphragmatic and chest wall rent has been uncommonly reported in literature. Also known as a transdiaphragmatic intercostal hernia (TDIH) or intercostal pleuroperitoneal hernia, it occurs when the disruption of diaphragmatic or intercostal muscles leads to an acquired herniation of abdominal contents. It is usually seen to occur following a traumatic incident. We report the case of an elderly male who presented with a reducible lump in the left chest and breathlessness on exertion, in the absence of any trivial or occult trauma, and how this was managed adequately via surgery alone.     

Thoraco-abdominal approach to large retroperitoneal tumours

OBJECTIVES: To evaluate the thoraco-abdominal approach for resection of retroperitoneal tumours, as this approach is rarely used because, although exposure is excellent, morbidity is presumed to be increased. PATIENTS AND METHODS: From October 2003 to September 2005, 21 patients (six female, 15 male), aged 14-76 years, underwent resection of very large and/or T4 retroperitoneal tumours through a thoraco-abdominal approach. RESULTS: In 16 (76%) patients tumour resection was complete. There were no significant complications during surgery. After surgery, there were complications in six patients (29%), in four of whom there was no long-term impairment. One patient died at 75 days after surgery from a complicated retroperitoneal haematoma. The mean (range) estimated blood loss was 2883 (50-20 000) mL, the intensive-care unit stay was 3.85 (0-30) days and the intermediate-care unit stay 2.6 (0-9) days. With a mean follow-up of 9.6 (1-19) months, 15 patients (72%) are recurrence-free, two (10%) have progressive disease, and four (19%) have died from malignancy. CONCLUSIONS: The thoraco-abdominal approach permits excellent exposure of the retroperitoneum for large and/or T4 tumours, allowing radical surgery in cases considered otherwise inoperable. Additional advantages are the possibilities of early vascular control and easy surgical extension of the procedure. These facts, combined with the reasonable morbidity found in our series, support the integration of the thoraco-abdominal approach in the regular options for urological surgery.