Successful repair of acquired intrathoracic nonmalignant tracheoesophageal fistulas using thoracoacromial artery perforator flap through a midsternal incision approach: a report of three cases.

Background: Acquired intrathoracic nonmalignant tracheoesophageal fistulas (TEFs) are rare and challenging surgical problems. They can constitute a life-threatening condition due to severe pulmonary complications and poor nutrition. Surgical treatment is effective for most patients undergoing operative repair. However, in recent studies, the difficult-to-ignore early complications of surgical treatment can be as high as 62.5%. Among them, esophageal stricture occurring in 42-54% of patients, anastomosis leakage occurs at a rate of 22.7-26%, and the mortality rate can be as high as 29.4%. Here, we introduce our innovative experience repairing acquired TEFs with a thoracoacromial artery perforator flap, in which provides a clear surgical field of view, reliable reconstruction, and no serious complications during the perioperative period and no mortality or complications were observed within 180 days after the operation. Case Description: Surgical repair with a thoracoacromial artery perforator flap through a midsternal incision approach was performed in 3 patients. During the procedure, a midsternal incision was made. After the thymus and anterior mediastinal fat were resected, and the left innominate vein was transected, the trachea and esophagus were mobilized. The trachea was incised and pulled to the cranial and caudal sides. Then, the thoracoacromial artery perforator flap was harvested and transferred into the superior mediastinum for esophageal reconstruction. Subsequently, the trachea was anastomosed end to end after debridement, and the left innominate vein was either anastomosed or not. Two patients developed esophageal anastomotic leakage postoperatively and healed well after nonsurgical treatment. No mortality or other complications were observed at 180 days after the operation. Conclusions: Repair of acquired TEFs using a thoracoacromial artery perforator flap through a midsternal incision approach is an effective, safe surgical treatment.

Associated risk factors for patients undergoing a unique or double Nuss bar placement for pectus excavatum.

BACKGROUND: Pectus excavatum is the most common chest wall deformity. Surgical correction via Nuss Procedure is a common approach. Patients with long-segment sternal depression require more than one Nuss bar to be inserted. Complications of Nuss procedure include surgical site infection and bar migration which may necessitate surgical re-intervention. There has been conflicting evidence regarding the safety profile of inserting two Nuss bars. We aim to specifically review the safety profile of two Nuss bar insertion and its complications. METHOD: 179 consecutive patients who had undergone Nuss procedure between November 2013 and November 2021 were identified. Data analysis was performed on patient's age at time of operation, gender, height, weight, Haller index, pre-existing medical conditions, indication for surgery, duration of operation, numbers of bars placed, length of stay, post-operative pneumothorax, bar migration, superficial and deep infections, need for surgical intervention and mortality. RESULT: Patients receiving two Nuss bars were at a significantly higher risk of developing infective complications. Lower weight and Haller index increase the risk of surgical site infection and infection requiring re-operation in this group of patients. A cut-off of 50 kg has a specificity of 92.1% with a sensitivity of 68.8% in regards to surgical site infection. CONCLUSION: Patients receiving two Nuss bars as a part of their Nuss procedure are at a significantly higher risk of developing infective complications. Selecting patients more than 50 kg to receive two Nuss bars appear to be a reasonable measure to reduce surgical site infection.

Surgical management of pleuro-peritoneal fistula in chronic renal failure patient-safety and effectiveness.

BACKGROUND: Pleuro-peritoneal fistula (PPF) is a known complication arising in patients receiving continuous ambulatory peritoneal dialysis (CAPD) as a form of renal replacement therapy with an incidence of approximately 2% (1). Previous literature has shown that the recurrence rate of non-operative management of PPF to be ~45%. Video-assisted thoracoscopic surgery (VATS) has been shown to be an effective and safe means of treating patients with PPF. However, to the author's knowledge, there is currently no sizeable case series that discuss the various intra-operative findings, operative techniques employed, post-operative complications, duration of peritoneal dialysis suspension and fistula recurrence in this particular patient group. METHODS: From January 2009 to January 2019, patients who underwent VATS for the repair of PPF at The Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Hong Kong were retrieved from the Clinical Data Analysis and Reporting System (CDARS). Patient's epidemiological data, comorbidities and surgical data were analyzed. RESULTS: There were 35 patients who underwent VATS PPF repair in our series. The mean age was 60.8 years (44 to 82 years), the (54.3%), mean operative time was 60.8 minutes (15-224 minutes). There were 8 patients (25.8%) who suffered from recurrence of pleural effusion after re-initiation of CAPD. Concomitant use of mechanical and talc pleurodesis was statistically significant in preventing PPF recurrence with an odds ratio of 0.1201 when compared to non-operative techniques. One patient suffered from hemothorax requiring re-operation on post-operative day one. There were no 30-day mortalities. CONCLUSIONS: VATS appears to be a safe and effective surgical treatment to prevent recurrence of continuous peritoneal dialysis associated PPF. Concomitant mechanical and talc pleurodesis appears to have additional benefit.