Technical considerations in robotic aberrant right subclavian artery resection for dysphagia lusoria.

Dysphagia lusoria occurs due to compression of the esophagus as an aberrant right subclavian artery (ARSA) crosses the mediastinum. Surgical management includes open, hybrid, and endovascular techniques, with no consensus gold standard. There are few reports of robotic-assisted ARSA resection. We describe the innovative technique and outcomes for two patients who successfully underwent robotic-assisted transthoracic resection of an ARSA after right carotid-subclavian bypass for dysphagia lusoria. Both patients experienced improvement or resolution of their dysphagia and no major complications. In select patients with a noncalcified origin of the ARSA without aneurysmal degeneration, the robotic-assisted approach represents a viable option.

Association Between Utilization of Services and Perioperative Outcomes for Lung Cancer Resection.

INTRODUCTION: Lung cancer resection has largely focused on perioperative outcomes (eg, mortality) to benchmark performance. While variations in perioperative outcomes and in utilization of services (eg, ambulatory procedures, hospitalization) have been independently demonstrated, there has been limited evaluation of associations between these outcomes. We evaluated the association between perioperative outcomes and utilization of services to evaluate provider performance across a broader context of care. PATIENTS AND METHODS: This was a retrospective cohort study of patients undergoing lung cancer resection in 2017 to 2019. We utilized hierarchical logistic regression models to determine risk- and reliability-adjusted mortality and risk-adjusted utilization of services, at the hospital-level. We then evaluated utilization of services across quartiles of perioperative mortality. RESULTS: A total of 15,168 patients across 297 hospitals underwent lung cancer resection. Mean risk- and reliability-adjusted 90-day mortality varied between 1.58% (95% CI, 1.54%-1.62%) and 2.74% (95% CI, 2.59%-2.90%) across quartiles. Risk-adjusted utilization of all ambulatory procedures was highest in the best performing (lowest mortality) quartile at 37.7% (95% CI, 33.6%-41.8%). Additionally, risk-adjusted inpatient utilization prior to and after surgery was lowest in the best performing quartile at 15% (95% CI, 13.7%-16.3%) and 19.3% (95% CI, 17.5%-21.0%), respectively. CONCLUSIONS: Hospitals with the lowest perioperative mortality demonstrated trends towards using more outpatient resources prior to surgery, but fewer inpatient services surrounding lung cancer resection. This correlation highlights the importance of incorporating utilization of services in addition to other metrics to profile the efficiency and effectiveness of centers performing lung cancer resection across a broader spectrum of care.

Obesity and the Latissimus Dorsi Flap: A Radiologic Study.

Introduction: The increasing prevalence of obesity in patients with breast cancer has prompted a reappraisal of the role of the latissimus dorsi flap (LDF) in breast reconstruction. Although the reliability of this flap in obese patients is well-documented, it is unclear whether sufficient volume can be achieved through a purely autologous reconstruction (eg, extended harvest of the subfascial fat layer). Additionally, the traditional combined autologous and prosthetic approach (LDF + expander/implant) is subject to increased implant-related complication rates related to flap thickness in obese patients. The purpose of this study is to provide data on the thicknesses of the various components of the latissimus flap and discuss the implications for breast reconstruction in patients with increasing body mass index (BMI). Methods: Measurements of back thickness in the usual donor site area of an LDF were obtained in 518 patients undergoing prone computed tomography-guided lung biopsies. Thicknesses of the soft tissue overall and of individual layers (e.g., muscle, subfascial fat) were obtained. Patient, demographics including age, gender, and BMI were obtained. Results: A range of BMI from 15.7 to 65.7 was observed. In females, total back thickness (skin, fat, muscle) ranged from 0.6 to 9.4 cm. Every 1-point increase in BMI resulted in an increase of flap thickness by 1.11 mm (adjusted R2 of 0.682, P < .001) and an increase in the thickness of the subfascial fat layer by 0.513 mm (adjusted R2 of 0.553, P < .001). Mean total thicknesses for each weight category were 1.0, 1.7, 2.4, 3.0, 3.6, and 4.5 cm in underweight, normal weight, overweight, and class I, II, III obese individuals, respectively. The average contribution of the subfascial fat layer to flap thickness was 8.2 mm (32%) overall and 3.4 mm (21%), 6.7 mm (29%), 9.0 mm (30%), 11.1 mm (32%), and 15.6 mm (35%) in normal weight, overweight, class I, II, III obese individuals, respectively. Conclusion: The above findings demonstrate that the thickness of the LDF overall and of the subfascial layer closely correlated with BMI. The contribution of the subfascial layer to overall flap thickness tends to increase as a percentage of overall flap thickness with increasing BMI, which is favourable for extended LDF harvests. Because this layer cannot be separated from overall thickness on examination, these results are useful in estimating the amount of additional volume obtained from an extended latissimus harvest technique.

Introduction: La prévalence croissante d'obésité chez les patientes atteintes du cancer du sein a suscité une réévaluation du rôle du lambeau du grand dorsal (LGD) en reconstruction mammaire. La fiabilité de ce lambeau est bien établie en cas d'obésité, mais on ne sait pas si le volume suffit pour effectuer une reconstruction purement autologue (p. ex., prélèvement élargi de la couche adipeuse sous-aponévrotique). De plus, en cas d'obésité, la combinaison habituelle de l'approche autologue et prothétique (LGD+expanseur et implant) est liée à un taux de complications plus élevé lié aux implants à cause de l'épaisseur du lambeau. La présente étude visait à obtenir des données sur l'épaisseur des diverses parties du grand dorsal et à traiter des conséquences de la reconstruction mammaire chez les patientes ayant un IMC plus élevé. Méthodologie: Les chercheurs ont mesuré l'épaisseur du dos au siège habituel de prélèvement du LGD chez 518 patientes dans le cadre d'une biopsie pulmonaire orientée par tomodensitométrie en position couchée. Ils ont mesuré l'épaisseur globale du dos et l'épaisseur de chaque couche dans cette région. Ils ont également obtenu les données démographiques des patientes, y compris l'âge, le genre et l'IMC. Résultats: Les chercheurs ont observé une fourchette d'IMC de 15,7 à 65,7. Chez les femmes, l'épaisseur totale du dos (peau, adiposité, muscle) variait entre 0,6 et 9,4 cm. Chaque point ajouté à l'IMC est associé à une augmentation de l'épaisseur du lambeau de 1,11 mm (rapport de cote rajusté [RCR] de 0,682, p<0,001) et à une augmentation de l'épaisseur de la couche adipeuse sous-aponévrotique de 0,513 mm (RCR de 0,553, p<0,001). L'épaisseur totale moyenne pour chaque catégorie de poids correspondait à 1,0, 1,7, 2,4, 3,0, 3,6 et 4, cm chez les patientes en insuffisance pondérale, de poids normal, en surpoids et obèses de classe I, II et III, respectivement. L'apport moyen de la couche adipeuse sous-aponévrotique à l'épaisseur du lambeau était de 8,2 mm (32 %) globalement et de 3,4 mm (21 %), 6,7 mm (29 %), 9,0 mm (30 %), 11,1 (32 %) et 15,6 mm (35 %) chez les patientes de poids normal, en surpoids et obèses de classe I, II, III, respectivement. Conclusion: Les résultats précédents démontrent que l'épaisseur globale du LGD et de la couche sous-aponévrotique est étroitement liée à l'IMC. L'apport de la couche sous-aponévrotique a tendance à être proportionnel à l'IMC en pourcentage de l'épaisseur globale du lambeau, ce qui est favorable à un prélèvement étendu du LGD. Puisque cette couche ne peut pas être séparée de l'épaisseur globale à l'examen, ces résultats sont utiles pour évaluer le volume supplémentaire obtenu à partir de la technique de prélèvement élargi du grand droit.

Posterior Interosseous Nerve Graft: Utilizing External Landmarks and Anthropometric Ratios to Predict Available Length for Digital Nerve Reconstruction in a Cadaveric Study.

Objective: In digital nerve defects that require grafting, autografts remain the efficacious option. The sensory posterior interosseous nerve (PIN) is an ideal choice as it is of similar caliber to digital nerves and leaves no donor morbidity upon resection. However, a finite length of harvestable PIN exists, and considerable variations of this length have been reported in the literature. There exists no predictive model to estimate this length. We sought to determine a method to accurately predict the available length of PIN based on individual patient anthropometry. Methods: A cadaveric dissection study was performed in a fresh tissue laboratory. The length of the sensory branch of the PIN and various anthropometric measurements were made in respect to surface anatomy of the ulna to develop a predictable ratio for available PIN donor graft. Results: A total of 16 specimens were obtained. On average the length of the PIN was 5.7 cm (range: 3.3-9. cm) and the length of the ulna was 25.7 cm (range: 23.5-30.6 cm). The ratio of PIN to ulnar length was 0.222 (r = 0.4651). Using one-fifth the length of the ulna, the mean predicted length of the PIN was 5.14 cm (range: 4.7-6.1 cm). On univariate analysis, there was no significant difference between the measured and predicted PIN length (P = .249). Conclusion: An anthropometric ratio predicated on reproducible surface anatomy of the ulna is a useful tool in predicting the sensory PIN length. Such a prediction may be a useful in guiding patient discussions concerning surgical options for digital nerve reconstruction.

Objectif: Dans les cas d'anomalies des nerfs digitaux qui exigent une greffe, les autogreffes sont les plus efficaces. Le nerf interosseux postérieur (NIP) sensitif est le choix idéal, car son calibre est semblable à celui des nerfs digitaux et qu'il ne provoque aucun problème de santé au site de résection. Cependant, la longueur du NIP pouvant être récolté est limitée, et d'énormes variations sont présentées dans les publications. Aucun modèle prédictif ne permet d'évaluer cette longueur. Les chercheurs ont entrepris d'établir une méthode pour prédire avec fiabilité la longueur disponible du NIP d'après les caractéristiques anthropométriques de chaque patient. Méthodologie: Les chercheurs ont procédé à une étude de dissection cadavérique dans un laboratoire de tissus frais. Ils ont mesuré le rameau sensitif du NIP et diverses dimensions anthropométriques d'après l'anatomie de surface de l'ulna pour établir un ratio prévisible de greffe du NIP disponible chez le donneur. Résultats: Les chercheurs ont obtenu 16 prélèvements et calculé une longueur moyenne du NIP de 5,7 cm (plage de 3,3 cm à 9,6 cm) et une longueur moyenne de l'ulna de 25,7 cm (plage de 23,5 cm à 30,6 cm). Ils ont calculé un ratio de 0,222 (r = 0,4651) entre la longueur du NIP et de l'ulna. D'après le cinquième de la longueur de l'ulna, ils ont prédit une longueur moyenne du NIP de 5,14 cm (plage de 4,7 cm à 6,1 cm). À l'analyse univariée, ils n'ont constaté aucune différence significative entre la longueur mesurée et prédite du NIP (P = 0,249). Conclusion: Le ratio anthropométrique établi d'après l'anatomie de la surface reproductive de l'ulna est un outil utile pour prédire la longueur du NIP sensitif. Une telle prédiction peut être utile pour orienter les échanges avec le patient au sujet des possibilités chirurgicales de la reconstruction du nerf digital.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block.

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Surface Landmarks to Provide a Safe Ulnar Nerve Block in the Wrist: Anatomical Study and Literature Review.

Introduction: Use of local anesthesia in awake patients undergoing hand surgery has become increasingly popular. A thorough understanding of local anatomy, such as the distal wrist for ulnar nerve block, is required to provide safe blockade. We sought to conduct an anatomic study of the distal wrist and review cadaveric studies describing various techniques for ulnar nerve block. Methods: Dissection of fresh-frozen cadaver forearms at the University of Louisville Robert Acland Fresh Tissue Lab assessing relationships between the flexor carpi ulnaris tendon and the ulnar nerve and the ulnar artery was performed. Three cadaveric studies on ulnar nerve blockade using the ulnar, volar, and/or transtendinous technique were identified and reviewed. Results: A total of 16 cadaver forearms of equal male to female ratio were obtained. The ulnar nerve was noted to be directly posterior to the flexor carpi ulnaris tendon in 15 (93.8%) forearms, with 1 (6.3%) specimen having the nerve extend along the ulnar border of the flexor carpi ulnaris. The ulnar artery was radial to the ulnar nerve 1 cm proximal to the pisiform in all specimens. In all 3 cadaveric studies, only the ulnar technique was associated with no ulnar artery and/or ulnar nerve injury. Conclusion: Knowledge of distal wrist anatomy can help minimize risk of iatrogenic injury during local blockade. On review, the ulnar approach provides the safest method for ulnar nerve block.

Breast Reconstruction With Local Flaps: Don't Forget Grandma.

Objective: Lateral breast defects of various causes can be reconstructed with random patterned local flaps utilizing oncoplastic techniques. These local flaps are used frequently in other areas but are infrequent in breast reconstruction despite affording excellent utility in small lateral defects. We sought to demonstrate this with a case series involving 5 patients who underwent oncoplastic breast surgery with random patterned flap reconstruction. Methods: From 2016 to 2017, 3 different varieties of random flaps were used in 5 women requiring lateral breast defect reconstruction secondary to resection of localized cancer or cutaneous lesion. The local flaps included a rhomboid flap, the bilobed flap, and a rotational flap. Patients were then evaluated in the clinic 10 to 12 months postoperatively for complications, symmetry, and satisfaction of reconstruction. Results: In 4 of 5 patients, the local flap remained fully viable and there was no incidence of seroma, infection, or further complications. One patient developed a post-operative hematoma requiring evacuation and a second patient experienced distal flap necrosis and delayed wound healing. Patients reported satisfaction with the reconstruction. Conclusions: Several random patterned local flaps exist for a variety of breast defects. They can yield excellent cosmetic results, high patient satisfaction, and bolster a low rate of complications. Our case series emphasizes the utility of random patterned flaps for lateral breast oncoplastic reconstruction.