Cardiac surgery and repair of pectus deformities: When and how?

OBJECTIVES: There is currently a lack of recommendations about patients with pectus deformities requiring cardiac surgery. This study reports the results of our surgical strategy on this issue. METHODS: Eleven patients, from three centers treated over a 9-year period were included in this study. Pectus deformities were operated with a modified Ravitch procedure. In the case of pectus excavatum repair and concomitant cardiac surgery, subperichondrial resection of abnormal rib cartilages was always performed before the sternotomy and an easily removable retrosternal metallic strut was inserted at the end of the procedure ensuring anterior chest wall stability. During follow-up patients had to estimate their current appearance with a numeric scale ranging from 0 to 100. RESULTS: Mean age was 27 ± 9.4 years. Pectus excavatum was present in 8 patients and pectus arcuatum in 3. There were 6 Marfan syndrome patients. Nine patients had concomitant surgery and, 2 underwent pectus repair after a history of cardiac surgery. There was no operative mortality. In the case of concomitant surgery, heart exposure through median sternotomy was facilitated by abnormal rib cartilage resection. Median follow-up was 54 months (range 16.7-119.7). Mean cosmetic result evaluated by the patients was 97.3 (±2.5). CONCLUSIONS: In adults, concomitant scheduled surgery is reliable and offers excellent long-term cosmetic results. Moreover, it allows a better thoracic exposition with no added perioperative risk. The modified Ravitch technique seems more adequate in these patients as it can be used in all types of pectus deformities.

Adjuvant antifungal therapy after pulmonary surgery for aspergilloma: is it useful?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether adjuvant antifungal therapy is useful after pulmonary surgery for aspergilloma. One hundred and sixteen papers were identified using the search described below, of which 5 papers presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No paper was greater than level-three evidence. One study compared the outcomes of 72 patients treated for pulmonary aspergilloma (PA) during a 23-year period. Despite no difference being found in outcomes, more complications were seen in the surgery-alone group. Another study included 14 patients treated with amphotericin B alone or with flucytocine. They found no benefit in the treatment of PA by systemic antifungal therapy. One retrospective study reported complete eradication of PA in patients treated with preoperative and postoperative oral itraconazole. One large cohort study reported their outcomes in 256 patients with PA, divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160) after aggressive surgical treatment and antifungal therapy. They found no difference in the postoperative morbidity between two groups (P = 0.27). A postoperative fungal relapse was found in 2 patients. One retrospective study reported the outcomes and mortality in 61 cases with PA. Thirty-five (60%) patients were treated with antifungal agents, and 15 (25%) patients were treated surgically. Many cases did not respond to antifungal therapy. Nineteen (31%) patients died. We did not find evidence to support the role of adjuvant antifungal therapy following definitive surgical removal of the fungus ball in immunocompetent patients; however, randomized control studies in multiple centres, with new antifungal therapy, are necessary to confirm these preliminary results.

Harvest technique for pedicled intrathoracic transposition of pectoralis major muscle.

Residual upper pleural spaces after subtotal pulmonary resection continues to pose great challenge for the thoracic surgeon. Although not all residual spaces deserve surgical attention, only in special situation (empyema with or without bronchopleural fistula). It increases morbidity, mortality, hospital stays, and costs. Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of this complication. Sometimes use of latissimus or serratus muscle might have been compromised by the incision for the original operation. In this situation the pectoralis major muscle flap (PMF) can be used successfully to reach and obliterate upper residual pleural space by anterior approach. The technique has never been specifically described before in the literature. We describe our technique for mobilization of PMF by anterior approach to obliterate residual upper space after major pulmonary resections.

Primary pulmonary myoepithelial carcinoma.

Primary salivary gland-type tumors of the lung are rare neoplasms. The pulmonary myoepithelial carcinoma belongs to this group. Since it was first described in 1998, we have identified only seven actual cases reported in the literature so far. We describe the case of a non-smoker 60-year-old Caucasian female, who was referred to our institution for the treatment of three peripheral nodules. Her medical history revealed that a wedge resection, for pulmonary myoepithelial carcinoma, was performed in another center 15 months previously. After resection of the current nodules, the histological findings showed three myoepithelial carcinomas of the lung. There was no vascular or lymphatic invasion. The hilar and mediastinal lymph nodes were negatives. The patient is doing well without any sign of recurrence. Herein we shall discuss the case of a primary pulmonary myoepithelial carcinoma in a female and propose a brief review of the literature.

Cardiopulmonary response following surgical repair of pectus excavatum in adult patients.

OBJECTIVE: Severe pectus excavatum are common in adult patients, often causing psychological complaints and physiological impairments. Although lung function at rest may minimally deteriorate after surgical correction, it remains unclear if surgery improves exercise capacity. The objective of present study is to assess whether the surgical repair of pectus excavatum in adults would improve exercise tolerance. METHODS: A prospective study was performed to compare pulmonary and cardiovascular function at rest and at maximal exercise, before, and at 1 year after pectus excavatum repair. RESULTS: From December 2005 to May 2009, 120 adult patients underwent pectus excavatum repair. Of these patients, 70 (nine women, 61 men) underwent thorough preoperative, 6-, and 12-month postoperative assessments, and were included in the present study. Age ranged from 18 to 62 years (mean 27 years). The pectus index (Haller index) was 4.5 ± 1.1. Lung function tests at rest were within the normal range, whereas maximal oxygen uptake (peak VO2) was only 77 ± 2% of the predicted value. At 1-year follow-up, the pectus excavatum repair was associated with minor changes in lung function tests and significant increase (p=0.0005) in VO2 (87 ± 2% of the predicted value). Postoperative O2 pulse increase at maximal exercise suggested that aerobic capacity improvement was the result of better cardiovascular adaptation at maximal workload. CONCLUSION: These results demonstrate sustained improvement in exercise cardiopulmonary function at 1-year follow-up of pectus excavatum surgical repair in adult patients.