Simultaneous minimally invasive uniportal atrial septal defect repair and pulmonary lobectomy: a case report.

Background: Combination of non-oncological pulmonary and cardiac conditions is common entity in modern thoracic surgery, allowing concurrent surgical correction. Multiple publications in the literature address the success of simultaneous interventions for combined conditions, however almost all are performed with an open approach. Case Description: A 49-year-old male with past medical history significant for bronchiectasis, complicated by fibrosis of the middle lobe, presented with dyspnea, recurrent hemoptysis, and nonproductive cough. Echocardiography revealed a large atrial septal defect (ASD), biventricular enlargement with severe mitral and tricuspid regurgitation. After multidisciplinary evaluation, patient was taken to the operating room for simultaneous cardiac intervention with right middle lobectomy. The total duration of surgery was 332 min, with cross-clamp time of 79 min. Estimated blood loss was 800 mL. Patient was extubated 3 h postoperatively, chest tube was removed on postoperative day 4 and the patient was discharged home on postoperative day 8 without postoperative complications. Conclusions: In this article, we describe the first case of simultaneous thoracoscopic uniportal intervention with cardiopulmonary bypass (CPB) in the treatment of multiple congenital heart defects and pulmonary complications of bronchiectasis. Presented case demonstrates potential advantage and feasibility of minimally invasive simultaneous procedures in patients with concurrent pulmonary and cardiac conditions. The described approach allowed radical surgical intervention to address both problems in the single setting, while retaining advantage of minimally invasive intervention.

Transsternal Approach for Broncho-Pleural Fistula Closure After Right Pneumonectomy.

Broncho-pleural fistula (BPF) is an abnormal communication between the bronchial lumen and the pleural space that typically occurs postoperatively. Surgical intervention is typically needed to patch the fistula; however, current literature lacks a gold standard for which treatment to use. With a high mortality rate, there is a clear urgency for quick and successful intervention. This case examines a 59-year-old patient presenting with a BPF 14 years after incidental pneumonectomy during upper lobectomy for invasive aspergillus. A fistula was appreciated during bronchoscopy with contrast injection. The fistula was closed via the transsternal approach through median sternotomy and pericardiotomy. This case report aims to provide a viable option to successfully repair a BPF via the transsternal approach.

A Rare Complication of Esophageal Exclusion: Esophageal Mucocele.

Bipolar esophageal exclusion is a "Hail Mary" procedure for control of leak and persistent mediastinal soilage from esophageal injury. Usually, the esophageal remnant scars down without negative consequences. Esophageal mucocele is a rare complication of bipolar esophageal exclusion. This is a case report of an iatrogenic esophageal transection and the subsequent treatment course. A retrospective chart review of the patient's medical and surgical history was performed. After a robotic hiatal hernia repair at an outside institution, the patient suffered an esophageal leak and was surgically treated with esophageal exclusion, wide drainage of the mediastinum, and decortication of the resulting empyema. She subsequently underwent retrosternal gastric conduit for esophageal reconstruction 4 months later. Three years after this, she developed a rare complication of esophageal exclusion, a symptomatic esophageal mucocele that required resection.

Robotic Transgastric Reconstruction of the Double Lumen Esophagus.

Double lumen esophagus is an extremely rare condition, developing in most cases as a complication of antireflux procedures or gastroesophageal reflux itself secondary to the severe inflammatory process in and around the lower esophagus. We describe a case of iatrogenic double lumen esophagus after multiple previous Nissen fundoplications for chronic gastroesophageal reflux disease. There is no standard surgical intervention for the management of this complication. We present a first report of successful robot-assisted surgical reconstruction of a double lumen esophagus.

Minimally Invasive Diaphragm Plication for Acquired Unilateral Diaphragm Paralysis: A Systematic Review.

Objective: Diaphragm paralysis is a relatively uncommon entity that can be both congenital and acquired in nature. While commonly asymptomatic, it can also cause a significant decrease in pulmonary function and reserve, particularly in patients with underlying pulmonary diseases. Our aim was to summarize the current literature regarding the minimally invasive techniques used in the surgical correction of acquired diaphragm paralysis via traditional and robotic minimally invasive approaches. Methods: We conducted a systematic review of available literature using the Cochrane methodology and reported findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Results: A total of 6,561 citations were identified through initial database and reference searches, of which 90 articles met the inclusion criteria for review. After further assessment, 33 appropriate full-text studies were selected for the review. Of the selected publications, the majority represented case reports and single-center retrospective studies with level of evidence 4. Only 1 level 2b study (individual cohort study) was identified, comparing minimally invasive and open approaches. Conclusions: Each of the minimally invasive approaches has its unique benefits and disadvantages, which are summarized and delineated in this article. Ultimately, no preferred method of diaphragm plication for diaphragm paralysis can be recommended at this time based on clinical data. The choice of procedure and surgical approach continues to be selected based on the surgeon's experience and preference.

Surgical management of rare benign tumors of the sternum.

Primary benign tumors of the sternum are an exceedingly rare entity. Surgical techniques regarding intervention for these lesions are not clearly defined in the literature given their scarcity. Operative techniques include en-bloc resection of the tumor, and this has proven to be successful in preventing local recurrence despite benign nature of the lesion. Given the often extensive defect created by the excision, reconstruction is frequently necessary; depending on the size of the defect, either autologous bone grafting or the use of synthetic materials may be indicated. This study serves to present two cases of rare primary benign tumors of the sternum, giant cell tumors and osteoma spongiosum and to summarize the available literature. We present a review of the literature of 17sternal giant cell tumor cases reported so far including our patient and unique case of osteoma spongiosum of the sternum, that discusses their surgical management, as well as reconstructive techniques that provided an excellent clinical result and a lack of recurrence on long term follow-up.

Surgical Management of Early Esophageal Cancer.

Esophageal cancer is the eighth most common cancer worldwide, and its incidence has been increasing over the past several decades. Esophagectomy currently is the standard of care for more advanced early esophageal cancer and should be performed at centers of excellence with high volumes, appropriate supportive staff, and multidisciplinary expertise.

Salvage Esophagectomy.

Salvage esophagectomy is an option for patients with recurrent or persistent esophageal cancer after definitive chemoradiation therapy or those who undergo active surveillance after induction chemoradiation therapy. Salvage resection is associated with higher rates of morbidity compared with planned esophagectomy but offers patients with locally advanced disease a chance at improved long-term survival. Salvage resection should be preferentially performed in a multidisciplinary setting by high-volume and experienced surgeons. Technical considerations, such as prior radiation dosage, radiation field, and choice of conduit, should be taken into account.

Surveillance Following Treatment of Esophageal Cancer.

We describe the surveillance strategies after esophageal cancer treatment, whether local therapy, induction chemoradiation, or other definitive treatment such as trimodality therapy. We discuss the shortcomings of the different invasive and imaging studies, and the recommended stage-specific surveillance after local and organ-sparing approaches to esophageal cancer treatment.

Peroral endoscopic myotomy: techniques and outcomes.

Achalasia is progressive neurodegenerative disorder of the esophagus, resulting in uncoordinated esophageal motility and failure of lower esophageal sphincter relaxation, leading to impaired swallowing. Surgical myotomy of the lower esophageal sphincter, either open or minimally invasive, has been a standard of care for the past several decades. Recently, new procedure-peroral endoscopic myotomy (POEM) has been introduced into clinical practice. This procedure accomplishes the same objective of controlled myotomy only via endoscopic approach. In the current chapter authors review the present state, clinical applications, outcomes and future directions of the POEM procedure.

Complex anterior chest wall reconstruction after extensive oncologic resections: a narrative review.

Objective: This report serves to showcase four cases of rare, malignant primary neoplasms of the anterior chest wall [chondrosarcoma and basal cell carcinoma (BCC)] that thoracic surgeons may encounter, and different approaches to complex reconstruction that may be necessary following resection. Background: Approximately 60% of the anterior chest wall neoplasms are malignant. The most common types of primary sternal tumors are chondrosarcoma and osteosarcoma. While guidelines for resection of these tumors have been previously described in the literature, guidelines regarding reconstructive techniques of the subsequent large defects are infrequently demonstrated. Methods: The medical records of four adult patients with primary chest wall tumors who underwent resection of the sternum from October 2016 to March 2021 were retrospectively reviewed. Radical resection with tumor-free surgical margins offers the best chance for survival, but results in a wide full-thickness defect. Hence, closure of the anterior chest wall defect with skeletal reconstruction is an essential step of the procedure and allows us to highlight surgical techniques and materials that have been used over recent years. Methods described herein include skeletal reconstruction with various hardware or allograft, as well as defect coverage using regional flaps, free tissue transfer, and mesh. Conclusions: Primary chest wall tumors of the sternum are an extremely rare diagnosis with a high malignancy rate. Full-thickness radical en-bloc resection is the most effective treatment option. Subsequent reconstruction of a wide chest wall defect is the most challenging aspect, though crucial in the preservation of the rigidity of the chest wall and protection of underlying structures. Different techniques and materials have been described without clear guidelines in treatment approaches; this paper serves to delineate and describe techniques that achieved successful outcomes.

EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty.

BACKGROUND: Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms. AIMS: We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation. METHODS: Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. RESULTS: Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml, 40 ml, and 50 ml than patients with little/no improvement (all p < 0.05). CONCLUSIONS: In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.

Self-Biased Bidomain LiNbO3/Ni/Metglas Magnetoelectric Current Sensor.

The article is devoted to the theoretical and experimental study of a magnetoelectric (ME) current sensor based on a gradient structure. It is known that the use of gradient structures in magnetostrictive-piezoelectric composites makes it possible to create a self-biased structure by replacing an external magnetic field with an internal one, which significantly reduces the weight, power consumption and dimensions of the device. Current sensors based on a gradient bidomain structure LiNbO3 (LN)/Ni/Metglas with the following layer thicknesses: lithium niobate-500 µm, nickel-10 µm, Metglas-29 µm, operate on a linear section of the working characteristic and do not require the bias magnetic field. The main characteristics of a contactless ME current sensor: its current range measures up to 10 A, it has a sensitivity of 0.9 V/A, its current consumption is not more than 2.5 mA, and its linearity is maintained to an accuracy of 99.8%. Some additional advantages of a bidomain lithium niobate-based current sensor are the increased sensitivity of the device due to the use of the bending mode in the electromechanical resonance region and the absence of a lead component in the device.

Thymic Neuroendocrine Tumors and Thymic Carcinoma: Demographics, Treatment, and Survival.

OBJECTIVE: Although rare, thymic neuroendocrine tumors (TNET) and thymic carcinoma (TC) are the most common thymic nonthymomatous malignancies; their survival outcomes have not been thoroughly compared. We analyzed the clinical, treatment, and survival characteristics of TNET and TC. METHODS: We retrospectively identified patients with a histologic diagnosis of TNET or TC in the National Cancer Database (2004 to 2015). Exclusion criteria were age <18 years and unstaged tumors. Descriptive statistics, survival analysis, and multivariable Cox regression analyses were used in elucidating associations. RESULTS: One thousand four hundred eighty-nine patients were included (TNET: 19.8%). Patients with TNET were significantly younger (57 vs 62.5 years), more likely to be male (70.5% vs 60.0%), and have localized tumors (45.4% vs 32.3%). Patients with TC more frequently underwent chemotherapy (56.1% vs 34.9%), radiation (56.9% vs 39.3%), and trimodality therapy (21.3% vs 11.5%), while resection rates were similar (55.3% vs 58.3%). The 5-year survival was 62% for TNET and 52% for TC, but comparable following multivariable adjustment. Age, stage, and Charlson-Deyo score were negative predictors of survival, while surgery and trimodality therapy were positive predictors. On subanalysis, adjuvant radiation therapy (ART) improved the survival of margin-positive tumors and was an independent predictor of survival for both tumor types (hazard ratio = 0.5). CONCLUSIONS: Our analysis of the largest series of TNET and TC showed a survival rate surpassing 50% at 5 years. These outcomes seem to be influenced by surgical resection and ART. Standardized staging and surgical protocols including lymph node sampling are still warranted to better elucidate the treatment algorithm of these tumors.

Tailoring Endoscopic and Surgical Treatments for Gastroesophageal Reflux Disease.

The incidence of gastroesophageal reflux disease (GERD) remains on the rise. Pathophysiology of GERD is multifactorial, revolving around an incompetent esophagogastric junction as an antireflux barrier, with other comorbid conditions contributing to the disease. Proton pump inhibitors remain the most common treatment of GERD. Endoscopic therapy has gained popularity as a less invasive option. The presence of esophageal dysmotility complicates the choice of surgical fundoplication. Most literature demonstrates that fundoplication is safe in the setting of ineffective or weak peristalsis and that postoperative dysphagia cannot be predicted by preoperative manometry parameters. More data are needed on the merits of endoluminal approaches to GERD.

Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How?

Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.

Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat?

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.