Safety of robotic first rib resection for thoracic outlet syndrome.

OBJECTIVES: Robotic first rib resection (R-FRR) is an emerging approach in the field of thoracic outlet syndrome (TOS) that has technical advantages over traditional open approaches, including superior exposure of the first rib and freedom from retracting neurovascular structures. We set out to define the safety of R-FRR and compare it with that of the conventional supraclavicular approach (SC-FRR). METHODS: We queried a prospectively maintained, single-surgeon, single-institution database for all FRR operations performed for neurogenic TOS and venous TOS. Preoperative, intraoperative, and complications were compared between approaches. RESULTS: Seventy-two R-FRRs and 51 SC-FRRs were performed in 66 and 50 patients, respectively. These groups were not significantly different in age, body mass index, sex, type of TOS, or preoperative use of opioids. Length of procedure and hospital stay were not different between groups. Postoperative inpatient self-reported pain (visual analog scale score 4.7 vs 5.2; P = .049) and administered morphine milligram equivalents (37.5 vs 81.1 MME, P < .001) were significantly lower in R-FRR than SC-FRR. Brachial plexus palsy was less frequent after R-FRR than SC-FRR (1% vs 18%, P = .002) and resolved by 4 months in call cases. All cases were sensory palsies with the exception of 2 motor palsies, which were both in the SC-FRR group. In multivariable analyses, R-FRR was independently associated with less frequent total complications than SC-FRR (P = .002; odds ratio, 0.08; 95% confidence interval, 0.02-0.39). CONCLUSIONS: R-FRR provides outstanding exposure of the first rib and eliminates retraction of the brachial plexus and its consequences.

Staging of Surgical Procedures in Comorbid Congenital Tracheal Stenosis and Congenital Cardiovascular Disease.

BACKGROUND: Comorbid long segment congenital tracheal stenosis and congenital cardiovascular abnormalities in children pose significant challenges with regard to repairing these abnormalities simultaneously or in stages. The aim of this study was to explore whether this combination of abnormalities needs a staged approach for surgical repairs. METHODS: All children who underwent both tracheal and cardiac surgical procedures at a tertiary hospital from 1995 to 2018 were analyzed retrospectively for mortality, ventilation days, postoperative intensive care unit days, mediastinitis, and unplanned reoperation by dividing them into simultaneous repairs (group 1), staged repairs within the same admission (group 2), and staged repairs during different admissions (group 3). RESULTS: Of 110 patients included in the study (group 1, 74; group 2. 10; and group 3, 26 patients), there was no significant difference in mortality (P = .85), median ventilation days (P = .99), median intensive care unit days (P = .23), unplanned airway reoperation (P = .36), and unplanned cardiac reoperation (P = .77). There was a significant difference in the rate of mediastinitis (group 1, 3%; group 2, 10%; and group 3, 19%; P = .02). There was no significant difference in 5-year survival (group 1, 86.2%; group 2, 77.8%; and group 3, 85.1%; P = .86). A higher STAT category was identified to be a risk factor for mortality in multivariate Cox regression analysis (relative risk, 5.45). CONCLUSIONS: Combined tracheal and cardiac abnormalities need a stratified approach to facilitate better clinical outcomes. Although the trajectory of care is often based on the clinical presentation, establishing a management protocol will be helpful, for which setting an international database will be useful.

[Which surgery for mediastinum tumor: Experience of the Department of thoracic surgery of CHU Hassan II of Fès]. / Quelle chirurgie pour quelle tumeur du médiastin : expérience du service de chirurgie thoracique de CHU Hassan II de Fès.

INTRODUCTION: Tumors of the mediastinum are a heterogeneous group of dysembryoplatic and neoplastic diseases essentially with different prognoses and therapeutic. These tumors develop slowly and remain long asymptomatic in 40-50% of cases. The purpose of our work is to bring the result of surgical management in diagnostic and therapeutic of principal mediastinum tumors framework. PATIENTS AND METHOD: We reviewed retrospectively the records of 68 patients in our training, between January 2009 and December 2013, for tumor of the mediastinum in the diagnostic framework and or therapy. RESULTS: There were 37 men and 31 women with a mean age of 37 years with extremes ranging from 11 to 73 years and 77.94% had an age between 11 and 50. In 39 patients, surgery had a diagnostic purpose (2 benign tumors and 37 malignancies including 27 cases of lymphomas). Curative surgery was performed in 34 patients, dominated by the tumors of thymic origin in 15 cases. Conventional surgery had involved 32 patients. The surgical approach was a total vertical sternotomy in 14 patients, in 17 patients was posterolateral thoracotomy and a left anterior thoracotomy in 1 patient. Video assisted thoracic surgery had been done in 3 patients under resection of a pleuropericardique cyst. Overall mortality was 4.41 percent. It is a death at D17 of the postoperative (thymoma with myasthenia) following a myasthenic crisis requiring a tracheotomy. A patient operated on for invasive thymoma developed myopathy and died at D44 of the postoperative following a difficulty of weaning. Another patient had a thymoma B3 benefited from 6 courses of neoadjuvant chemotherapy and then a thymectomy had presented a respiratory distress with bilateral pleural effusion, death at D10 of the postoperative by septic shock following a nosocomial infection. CONCLUSION: Tumors of the mediastinum are infrequent, discovered more often by chance. The main prognostic factor is the completeness of tumor resection without taking the break. Conventional surgery always keeps a place in our context, despite the advent of minimally invasive surgery.

[Acute pain syndrome and levels of peripheral blood saturation after various thoracic surgical approaches].

The traumatic effect of surgical approaches was determined by the intensity and duration of pain syndrome and by the degree of lung ventilation disturbances after thoracic surgery. An acute pain syndrome was considered by visual analog pain scale and a blood saturation level for the first 5 days after operation. There were 3 groups, each group consisted of 31 patients. All patients were after thoracotomies, thoracoscopies, rethoracoscopies. Maximal intensity of pain appeared to be after thoracotomies and its degree has been reducing since the first till fifth day (from 8.1 +/- 1.7 to 4.2 +/- 0.9 points). The pain syndrome was reliably less after thoracoscopy (from 5.9 +/- 1.6 to 3.5 +/- 1.4 points). Minimal pain was noted after revideothoracoscopies with the dynamics from 4.0 +/- 2.4 to 2.7 +/- 1.2 points. The rate of blood saturation was more reduced after thoracotomy for the first two days till 92.9 +/- 4.6% and the saturation level became equal on the third day in all groups. Obtained data objectively confirmed the considerably less injury in the case of endoscopic thoracic approaches in comparison with open intervention.

Initial treatment of isolated thoracic injuries.

INTRODUCTION: Isolated thoracic injuries are relatively common and they are on the second place as a cause of death overall trauma. Most patients with isolated thoracic injuries are treated on an outpatient basis while only serious cases are hospitalized. The basis of the treatment of thoracic trauma is efficient cardiopulmonary reanimation followed by an early detection and treatment of life threatening injuries. Less than 15% of patients with thoracic trauma require thoracotomy. PATIENTS: Only the patients with exclusively isolated thoracic trauma were analyzed. RESULTS: Based on initial diagnostic procedures initial conservative treatment was indicated and sufficient for 63.75% (204/320) cases while initial surgery treatment was necessary in 36.25% (116/320) of the injured. In relation to the type of surgery the thoracic drainage was performed in 81.03% (94/116) while thoracotomy and VATS procedure was necessary for 7.75% (9/116) of the injured. After the secondary examination or shorter monitoring of the status of the injured, the additional diagnostic procedure was suggested and performed in only 5% (16/320) of the injured. The average period of the hospitalization for all injured with isolated thoracic trauma was 5.9 +/- 4.0 days (from 6 hours to 16 days). In cases of patients with blunt injuries the average period of hospitalization was 6.07 +/- 4.26 days, while for the patients with penetrating trauma it was 5.4 +/- 3.36 days. The calculated value oft-student test (0.2766 > 0.05) indicates that there is no statistically significant difference in the period of the hospitalization in relation to the type of trauma (blunt vs. penetrating). The average period of thoracic drainage was 5.58 +/- 3.3 days (from 3 to 17 days). The average duration of thoracic drainage in the patients with blunt trauma was 5.81 +/- 2.67 days, while in the patients with penetrating trauma it was 5.08 +/- 1.99 days. The calculated value of the probability of t-test (0.1478 > 0.05) shows that there is no significant difference in the period of drainage in cases of blunt and penetrating trauma. Out of total number of patients, 98.0% (315/320) of the injured were successfully treated. The complications were found in 1.25% (4/320) cases. Death was the outcome in 1.5% (5/320) of injured. CONCLUSION: Based on the results of the initial diagnostic treatment, in majority of injured with isolated thoracic trauma, it was possible to conduct the relevant and appropriate therapeutic procedures. On the basis of relatively short period of thoracic drainage, hospitalization and low rates of morbidity and mortality, it may be confirmed that the application of initial diagnostic and therapeutic protocols of the Clinic for thoracic surgery resulted in the achievement of the successful treatments in majority of the injured for this type of the

Evaluating the reliability and reproducibility of the Ottawa Thoracic Morbidity and Mortality classification system.

BACKGROUND: Minimizing adverse events after surgery is widely recognized as an important indicator of quality; yet no consensus has been reached on how to standardize the reporting of adverse events after surgical procedures. Our objectives were to develop a standardized classification system to monitor both the presence and severity of thoracic morbidity and mortality, and to evaluate its reliability and reproducibility among a national cohort of thoracic surgeons. METHODS: To assess the Thoracic Morbidity and Mortality classification system (based on the Clavien-Dindo classification of adverse events), a 31-item questionnaire was sent to all members of the Canadian Association of Thoracic Surgeons in August 2009, consisting of a general description of the Thoracic Morbidity and Mortality severity grades, 20 case-based questions of postoperative adverse events to be classified, and questions regarding personal judgments. We derived descriptive and quantitative information using weighted Kappa statistics. RESULTS: Fifty-two (54.7%) thoracic surgeons completed the questionnaire; 41 (78.8%) of the respondents were affiliated with an academic teaching hospital. A total of 1,326 individual weighted Kappa statistics were calculated for all distinct pairs of raters, of which 1,152 (87%) were greater than 0.81, a range that is interpreted as "almost perfect agreement." A further 174 (13%) were in the range between 0.61 and 0.8, interpreted as "substantial agreement." All results were statistically significant (p < 0.0001). The classification system was regarded as straightforward (98% of the respondents), reproducible (94%), logical (92%), and useful (98%). CONCLUSIONS: The modified classification system appears to offer objective, reliable, and reproducible reporting of thoracic morbidity and mortality, and thus may assist continuous quality improvement in thoracic surgery.

Tratamento cirúrgico de crianças com pneumonia necrosante / Surgical treatment of children with necrotizing pneumonia

OBJETIVO: Descrever os resultados do tratamento cirúrgico de crianças com pneumonia necrosante. MÉTODOS: Análise retrospectiva dos prontuários de 20 crianças diagnosticadas com pneumonia necrosante e submetidas ao tratamento cirúrgico nos serviços de cirurgia torácica de dois hospitais na cidade de Manaus (AM) entre março de 1997 e setembro de 2008. Dados referentes a idade, sexo, agente etiológico, motivos da indicação cirúrgica, tipo de ressecção cirúrgica realizada e complicações pós-operatórias foram compilados. RESULTADOS: Dos 20 pacientes analisados, 12 (60 por cento) eram do sexo feminino. A média de idade dos pacientes foi de 30 meses. Os agentes etiológicos mais encontrados foram Staphylococcus aureus, em 5 pacientes (25 por cento), e Klebsiella sp., em 2 (10 por cento). Os motivos de indicação cirúrgica foram sepse, em 16 pacientes (80 por cento), e fístula broncopleural, em 4 (20 por cento). Os tipos de procedimentos cirúrgicos realizados foram lobectomia, em 12 pacientes (60 por cento), segmentectomia, em 7 (35 por cento), e bilobectomia, em 1 (5 por cento). Além desses procedimentos, 8 pacientes (40 por cento) foram submetidos à descorticação pulmonar. As complicações pós-operatórias foram as seguintes: fístula broncopleural, em 4 pacientes (20 por cento); empiema, em 1 (5 por cento); pneumatocele, em 1 (5 por cento); e flebite em membro superior esquerdo, em 1 (5 por cento). Quatro pacientes (20 por cento) morreram. CONCLUSÕES: Pacientes com evidências de necrose pulmonar devem ser considerados para a ressecção cirúrgica, que está indicada em casos graves de sepse, fístula broncopleural de alto débito ou insuficiência respiratória aguda que não respondem ao tratamento clínico.

OBJECTIVE: To describe the results of the surgical treatment of children with necrotizing pneumonia. METHODS: A retrospective analysis of the medical charts of 20 children diagnosed with necrotizing pneumonia and submitted to surgical treatment between March of 1997 and September of 2008 in the thoracic surgery departments of two hospitals in the city of Manaus, Brazil. We compiled data regarding age, gender, etiologic agent, indications for surgery, type of surgical resection performed, and postoperative complications. RESULTS: The mean age of the patients was 30 months. Of the 20 patients studied, 12 (60 percent) were female. The most common etiologic agents were Staphylococcus aureus, in 5 patients (25 percent), and Klebsiella sp., in 2 (10 percent). The indications for surgery were sepsis, in 16 patients (80 percent), and bronchopleural fistula, in 4 (20 percent). The types of surgical procedures performed were lobectomy, in 12 patients (60 percent), segmentectomy, in 7 (35 percent), and bilobectomy, in 1 (5 percent). There were 8 patients (40 percent) who also underwent decortication. The postoperative complications were as follows: bronchopleural fistula, in 4 patients (20 percent); empyema, in 1 (5 percent); pneumatocele, in 1 (5 percent); and phlebitis of the left arm, in 1 (5 percent). Four (20 percent) of the patients died. CONCLUSIONS: Surgical resection should be considered in patients with evidence of pulmonary necrosis. Resection is indicated in cases of severe sepsis, high output bronchopleural fistula, or acute respiratory failure that are refractory to clinical treatment.

Surgical treatment of children with necrotizing pneumonia.

OBJECTIVE: To describe the results of the surgical treatment of children with necrotizing pneumonia. METHODS: A retrospective analysis of the medical charts of 20 children diagnosed with necrotizing pneumonia and submitted to surgical treatment between March of 1997 and September of 2008 in the thoracic surgery departments of two hospitals in the city of Manaus, Brazil. We compiled data regarding age, gender, etiologic agent, indications for surgery, type of surgical resection performed, and postoperative complications. RESULTS: The mean age of the patients was 30 months. Of the 20 patients studied, 12 (60%) were female. The most common etiologic agents were Staphylococcus aureus, in 5 patients (25%), and Klebsiella sp., in 2 (10%). The indications for surgery were sepsis, in 16 patients (80%), and bronchopleural fistula, in 4 (20%). The types of surgical procedures performed were lobectomy, in 12 patients (60%), segmentectomy, in 7 (35%), and bilobectomy, in 1 (5%). There were 8 patients (40%) who also underwent decortication. The postoperative complications were as follows: bronchopleural fistula, in 4 patients (20%); empyema, in 1 (5%); pneumatocele, in 1 (5%); and phlebitis of the left arm, in 1 (5%). Four (20%) of the patients died. CONCLUSIONS: Surgical resection should be considered in patients with evidence of pulmonary necrosis. Resection is indicated in cases of severe sepsis, high output bronchopleural fistula, or acute respiratory failure that are refractory to clinical treatment.

[Evaluation of thoracic surgical practice. The impact of specialisation and the effect of volume on the results of cancer treatment: resectability, post-operative mortality, and long-term survival]. / Evaluation des pratiques en chirurgie thoracique.

INTRODUCTION AND METHODS: The impact of the volume of activity and the specialisation of the surgeon and the hospital on the quality of health care for patients with non-small cell lung cancer (NSCLC) was evaluated from the publications over the last 20 years. RESULTS: The statistics, based mainly on administrative data, identified a significant decrease in post operative mortality (5 out of 7 studies) and improved long-term survival (2 out of 3 studies) in establishments undertaking large numbers of lung resections. The threshold for defining high volume groups varied from study to study (from 28 to 128 procedures per year). The same tendency was seen among the surgeons where specialisation in thoracic surgery led to higher levels of resectability and parenchymal preservation. CONCLUSIONS: These results should be interpreted with caution on account of the nature of the data and the methodology employed. A certification of referral centres, validated by the French Thoracic and Cardiovascular Surgical Society, based on the training, level of activity in cancer surgery, and the infrastructure of the hospital should lead to a more even standard of care for patients with NSCLC.

Thoracic and cardiovascular surgery in Japan during 2003: annual report by The Japanese Association for Thoracic Surgery.

The Japanese Association for Thoracic Surgery has conducted annual surveys of thoracic surgery to reveal the statistics of the number of procedures according to the operative category throughout the country since 1986. Here we have summarized the results from our annual survey of thoracic surgery performed during 2003. The incidence of hospital mortality was added to this survey to determine the nationwide status that could be useful not only for surgeons to compare their work with that of others, but also for the association to gain a better understanding of present problems as well as future prospects. Thirty-day mortality (sometimes termed operative mortality) is death within 30 days of operation regardless of the patient's geographic location. Thirty-day mortality includes death within 30 days of operation even though the patient is discharged from the hospital within 30 days of operation. Hospital mortality is death within any time interval after operation if the patient is not discharged from the hospital. Hospital-to-hospital transfer is not considered discharge; transfer to a nursing home or a rehabilitation unit is considered hospital discharge unless the patient subsequently dies of complications of the operation (the definitions of terms are based on the published guidelines of the Society of Thoracic Surgeons and the American Association for Thoracic Surgery (Edmunds LH, et al. Ann Thorac Surg 1996; 62: 932-5)). Thoracic surgery was classified into three categories as cardiovascular, general thoracic and esophageal surgery, and the pertinent data were examined and analyzed in each group. Access to the computerized data is offered to all members of this association. We honor and value your continued kind support.

Dissecções agudas da aorta torácica / Acute dissections of thoracic aorta

O objetivo do trabalho é relatar a experiência com 22 pacientes portadores de dissecção aguda da aorta torácica, em suas diversas formas, que foram tratados cirurgicamente no Hospital de Cardiologia de Laranjeiras - RJ, no período compreendido entre 1990 e 1995. Comentar os vários aspectos cirúrgicos (pré, per e pós-operatórios), bem como fazer uma análise comparativa dos dados obtidos com os da literatura mundial. Várias técnicas cirúrgicas foram empregadas, dependendo do tipo da dissecção, com discreta predominância para a técnica de Bentall-Debono, utilização de tubo valvado com posterior reimplante de coronárias, nos casos em que havia comprometimento de valva aórtica (insuficiência) associado, utilizada em 10 casos (45,4 por cento); além da interposição de enxerto com anastomoses proximal e distal após ressecção total do segmento aórtico comprometido, utilizada em sete paciente (31,8 por cento); e o implante de enxerto intraluminal, com extremidades distal livre("tromba de elefante"), realizada em cinco cirurgias (22,7 por cento). A mortalidade geral foi de 18,1 por cento (quatro pacientes) e o seguimento dos sobreviventes se fez (até o presente momento) num período médio de 24 meses. As complicações pós-operatórias (não-fatais) observadas foram: arritmias, discrasia sangüínea, alterações respiratórias e renais, tromboembolismo pulmonar e diástese de sutura do esterno. O tratamento cirúrgico das dissecções agudas da aorta torácica é passível de conviver com bons resultados, a despeito das condições hemodinâmicas dos pacientes serem, geralmente, ruins; desde que o tratamento cirúrgico adequado seja prontamente realizado. Quanto às técnicas utilizadas, tanto melhores serão os resultados quanto mais criteriosa a sua escolha, levando-se em consideração as características da dissecção e as condições cirúrgicas existentes

A new method for digital video documentation in surgical procedures and minimally invasive surgery.

BACKGROUND: Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article. METHODS: We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1-17), and the median storage volume was 49 MB (range, 3-360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations. CONCLUSION: This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.

Results of continual devaluation of cardiothoracic surgical codes by the HCFA between 1984 and 1999.

BACKGROUND: The devaluation of surgical procedural services by Medicare began in 1989 as a result of the federal government's adoption of the Resource Based Relative Value Scale, a method of redistribution of payments to physicians from surgical to primary care services. This method gave to the Health Care Financing Administration (HCFA) effective and complete control of Medicare payments to physicians for the first time. The resultant decrease in the nominal dollar value is well understood, but the effect of changes in inflation frequently is not calculated into the reported loss. METHODS: A method of determining the true extent of this devaluation using the nominal dollar decrease plus the effect of inflation was presented in 1995. RESULTS: Since then, repeated devaluation by the HCFA and other third parties plus continual inflation has further eroded the remuneration for cardiothoracic surgical services. Three different sets of data are used to determine the devaluation of five cardiothoracic operations. One set shows the change between 1988 and 1998; one the change between 1988 and 1999; and one the change between 1984 and 1999. CONCLUSIONS: Depending on the geographic location, it appears that the remuneration for pulmonary procedures between 1988 and 1999 decreased 35% to 60%. Similarly, depending on the years reviewed (between 1984 and 1999) and the geographic location, the fee for cardiac procedures decreased 46% to 69%.

Modelling and reclassification of surgical procedures--experiences from the use of GALEN methods in the domain of thoracic surgery.

This paper reports on experiences from the evaluation of GALEN methods for mapping of follow-up categories in the domain of thoracic surgery to an existing classification of surgical procedures. The mapping of the aggregated levels or groups of thoracic procedures presents a genuine problem in relation to strict hierarchical classifications, since the follow-up categories do not necessarily fit in the pre-set structure of the classification. Experiences from modelling of the traditional classification and of the follow-up categories are reported, and an analysis of the results is presented along with a discussion of opportunities and potential problems and pitfalls when applying GALEN models and tools.

Aggregation and reclassification--assessment of GALEN methods in the domain of thoracic surgery.

This paper reports on the experiences from evaluation of GALEN methods for mapping of follow-up categories in the domain of thoracic surgery to an existing classification of surgical procedures. The mapping of the aggregated levels or groups of thoracic procedures presents a genuine problem in relation to strict hierarchical classifications, since the follow-up categories not necessarily fit in the pre-set structure of the classification. The paper reports on the experiences from modelling of the traditional classification as well as modelling of the follow-up categories, together with an analysis of results with a discussion of opportunities and potential problems and pitfalls when applying GALEN models and tools.

[Classification of surgical procedures in lung cancer]. / Klassifikatsiia operativnykh vmeshatel'stv pri rake legkogo.

Various aspects of classification of surgical operations in cancer of the lung are presented. The authors suggest their supplement and changes in systematization of surgical interventions in malignant tumors of the lungs published by V.I. Chissov et al. (1995). Basing on the study and analysis of many years experience in surgical treatment of patients with advanced stages of lung cancer in the clinic of thoracic surgery of the Military Medical Academy, the authors suggest classification of combined operations which takes into account both a character and an extent of an extrapulmonary spread of the tumors and thus reflects peculiarities and a high degree of traumatism of surgical intervention and allows to approach more differentially to the assessment of initial and long-term results of surgical treatment of patients.