Prevalence and morphometry of sternal and xiphoid foramen: a meta-analysis on 16,666 subjects.

PURPOSE: Sternal foramen is a perforation of the sternum that can be a source of misdiagnosis during radiographic imaging or life-threatening perforations during bone marrow sampling. The aim of this study was to conduct a meta-analysis on the prevalence, morphometrics, and location of foramen in the sternal body and xiphoid process, describe morphometric features of this phenomenon, and thus verify its clinical importance. Moreover, our secondary outcome was to compare effectiveness of various imaging methods in diagnosis of the sternal or xiphoid foramen. METHODS: A comprehensive search was conducted on major scientific databases to identify studies containing relevant information. Data on foramen's prevalence, location, morphometrics, and accompanying findings were extracted and pooled into a meta-analysis using MetaXL 5.0. RESULTS: Thirty-five studies (n = 16,666 subjects) were included. The overall pooled prevalence of a foramen in the sternal body and/or a xiphoid process was 8.9% (95% CI 6.5-11.7) and it equaled 6.5% (95% CI 5.6-7.6) for sternal body alone and 2.9% (95% CI 0.5-6.9) for the xiphoid process. The foramen was more prevalent in males than in females (12.2% vs. 6.8%). The prevalence of sternal foramen was higher in South American [13.9% (95% CI 11.2-16.9)] and African [13.6% (95% CI 9.7-18.0)] studies compared to North American [6.2% (95% CI 5.0-7.5)] and European populations [8.6% (95% CI 3.1-16.3)]. Mean transverse and vertical diameter of foramen equaled 4.7 mm (95% CI 3.8-5.5), and 5.6 mm (95% CI 4.2-6.9), respectively. CONCLUSION: Our analysis proves that the sternal foramina are structures of significant prevalence and size. Any physician should keep them in mind when performing punctures in this area.

Accuracy of the corrected nose-earlobe-xiphoid distance formula for determining nasogastric feeding tube insertion length in intensive care unit patients: A prospective observational study.

BACKGROUND: As nasogastric feeding tube insertion is a frequently applied, non-risk-free nursing technique, a high level of evidence-based nursing care is required. Little evidence is available regarding the accurate determination of the insertion length of nasogastric feeding tubes. The method of using the nose-earlobe-xiphoid distance as measurement is inadequate and not supported by evidence. Findings from a recent randomized trial led to an alternative calculation: the corrected nose-earlobe-xiphoid distance formula: (nose-earlobe-xiphoid distance × 0.38696) + 30.37 + 6 cm. OBJECTIVES: To test the accuracy of the corrected nose-earlobe-xiphoid distance formula for determining the required nasogastric feeding tube insertion length in adults admitted on an intensive care unit and to investigate the probability to successfully obtain gastric aspirate for pH measurement. DESIGN: Prospective, single-center observational study. PARTICIPANTS AND METHODS: Adult intensive care unit patients in a general hospital (N = 218) needing a small-bore nasogastric feeding tube were included between March and September 2018. Correct tip positioning was defined as a tube tip located > 3 cm under the lower esophageal sphincter. Tip positioning was verified using X-ray. RESULTS: All nasogastric feeding tube tips were correctly positioned > 3 cm under the lower esophageal sphincter. The chance of successfully obtaining gastric aspirate within 2 h after placement of the tube was 77.9%. CONCLUSIONS: With all tips positioned > 3 cm in the stomach and zero tubes migrating back into the esophagus, the corrected nose-earlobe-xiphoid distance formula can be considered a more accurate method to determine nasogastric feeding tube insertion length.

Subxiphoid uniportal bilateral lung wedge resection.

Subxiphoid uniportal bilateral lung wedge resection, in which all manipulations are performed via a 3-cm wound positioned below the xiphoid process, can be performed in the supine position without the patient having to change positions. It also enables one-stage bilateral lung resection. We report the surgical procedure and initial results of subxiphoid uniportal bilateral lung wedge resection. A 3-cm transverse incision was made 1 cm caudally below the xiphoid process. A port for uniportal surgery was inserted. After CO2 insufflation at 8 mmHg, the lung was grasped and lifted with bent grasping forceps, and by bending the tip of a stapler, the surgeon resected the affected portion of the bilateral lungs. In this approach, there is one incision, no intercostal nerve damage and bilateral surgery can be performed in the same procedure; therefore, the technique may have the benefit of lesser invasiveness for the patient. Furthermore, a detailed comparison of subxiphoid uniportal bilateral lung wedge resection with the one-stage lateral intercostal approach with a larger subject sample is needed.

Methods of Estimating Nasogastric Tube Length: All, Including "NEX," Are Unsafe.

BACKGROUND: Predominance of blind feeding tube placement makes esophageal tube misplacement and aspiration risk commonplace. Accurate estimation of nose-to-stomach length could reduce this risk. Standards for estimating this length were audited against the length measured from guided tube placement. METHODS: This prospective, single-center observational study used electromagnet-guided tube placement to measure the length from nose to gastric body flexure as part of routine care. This measurement was used to audit standard equations used to estimate this length from external measures: xiphisternum-ear-nose + 10 cm (XEN+10), nose-ear-xiphisternum (NEX), and Hanson_A and Hanson_B. RESULTS: From April 23, 2015, to March 2, 2020, measurements were obtained from 200 primary tube placements. Median length to the gastric body flexure (61 cm) was significantly different from that to the pre-gastroesophageal junction flexure (48 cm) or lengths predicted by NEX (51 cm) or Hanson_A (50.5 cm) and Hanson_B (56.1 cm) (all P < .00001) but similar to XEN+10 (61 cm). Esophageal placement was a potential risk for all methods (NEX: 96.3%, Hanson_A: 99.5%, Hanson_B: 86.9%, XEN+10: 43.2%) and a definite risk for most (NEX and Hanson_A: 14.9%, Hanson_B: 1%, XEN+10: 0%). CONCLUSIONS: NEX and Hanson methods of predicting the length from nose to gastric body flexure are too short and risk esophageal misplacement. XEN+10 reduces but does not eliminate this risk. External measurement predictions are clinically unsafe as a guide blind tube placement. Guided placement is recommended.

Prevalence of pectus excavatum in an adult population-based cohort estimated from radiographic indices of chest wall shape.

BACKGROUND: Pectus excavatum is the most common chest wall skeletal deformity. Although commonly evaluated in adolescence, its prevalence in adults is unknown. METHODS AND FINDINGS: Radiographic indices of chest wall shape were analyzed for participants of the first (n = 2687) and second (n = 1780) phases of the population-based Dallas Heart Study and compared to clinical cases of pectus (n = 297). Thoracic computed tomography imaging studies were examined to calculate the Haller index, a measure of thoracic axial shape, and the Correction index, which quantitates the posterior displacement of the sternum relative to the ribs. At the level of the superior xiphoid, 0.5%, 5% and 0.4% of adult Dallas Heart Study subjects have evidence of pectus excavatum using thresholds of Haller index >3.25, Correction index >10%, or both, respectively. Radiographic measures of pectus are more common in females than males and there is a greater prevalence of pectus in women than men. In the general population, the Haller and Correction indices are associated with height and weight, independent of age, gender, and ethnicity. Repeat imaging of a subset of subjects (n = 992) demonstrated decreases in the mean Haller and Correction indices over seven years, suggesting change to a more circular axial thorax, with less sternal depression, over time. CONCLUSIONS: To our knowledge, this is the first study estimating the prevalence of pectus in an unselected adult population. Despite the higher reported prevalence of pectus cases in adolescent boys, this study demonstrates a higher prevalence of radiographic indices of pectus in adult females.

Does nonexistent of your hands on the screen guarantee no radiation exposure to your body? - Study on exposure of the practitioner's hands to radiation during C-arm fluoroscopy-guided injections and effectiveness of a new shielding device.

Observational phantom study.This study aimed to evaluate the radiation exposure dose of practitioner's hands when performing C-arm guided procedures and to determine the usefulness of our newly designed radiation shielding device.C-arm guided procedures including lumbar transforaminal epidural steroid injections (TFESIs) are commonly used for pain control induced by lumbar radiculopathy. The practitioner's hands are vulnerable to radiation exposure because of the long exposure time and short distance from the radiation resource. No studies to date have reported the cumulative exposure of the physician's hands according to location and exposure time.Using a chest phantom irradiated with X-rays under lumbar TFESI conditions, cumulative scatter radiation dose was measured at 36 points using a dosimeter. The measurements were checked at 1, 3, 5, 10 minutes of radiation exposure. The experiment was repeated using our newly designed shielding device.Significant radiation accumulation was observed in the field where the practitioner's hands might be placed during C-arm guided procedures. The further the distance from the radiation resource and the shorter the exposure time, the smaller was the cumulative radiation expose dose. The new shielding device showed an excellent shielding rate (66.0%-99.9%) when the dosimeter was within the shielding range. However, at some points, increased accumulated radiation exposure dose was observed, although the dosimeter was within the range of the shielding device.To reduce radiation exposure of the practitioner's hands when performing C-arm-guided procedures, the radiation exposure time should be decreased and a greater distance from the radiation resource should be maintained. When using our shielding device, placing the hand close to the device surface and minimizing the time using fluoroscopy minimized the radiation exposure of the hand.

Heterotopic Ossification of the Xiphoid After Chest Compressions.

This report describes the case of a 56-year-old woman with a 6-year history of severe epigastric pain after chest compressions for cardiac arrest. A comprehensive gastrointestinal workup was negative. However, an abdominal computed tomographic scan demonstrated an elongated xiphoid process. After a xiphoid trigger point injection, she experienced pain relief lasting 4 days, and thus her symptoms were attributed to xiphoidalgia secondary to heterotopic ossification after trauma. She underwent open resection of the xiphoid process. Heterotopic ossification of the xiphoid process is rare. This report documents a case of heterotopic ossification secondary to trauma from chest compressions.

Xiphoidectomy for Intractable Xiphodynia.

BACKGROUND: Xiphodynia is a rare condition with hardly any data published regarding xiphoidectomy as a valid treatment option for intractable disease. It is necessary to bear this syndrome in mind after having filtered out other differential diagnoses. METHODS: Between 2003 and 2015, 11 patients underwent xiphoidectomy for intractable xiphodynia at our institution. Patients' charts were reviewed including preoperative workup, operative technique, and results. Every patient had routine follow-ups, 4 weeks after the procedure and 1 year after surgery. RESULTS: The main symptom was chest pain in the area of the xiphoid. Conservative treatment trials with different combinations of analgesics over at least 1 year did not lead to insufficient and long-term improvement, which is why the decision for a surgical xiphoidectomy was eventually made. No postoperative complications occurred. Significant pain relief was achieved in eight out of ten patients; one patient was lost to long-term follow-up. Both patients with insufficient pain relief have had previous surgery in form of a sternotomy and upper median laparotomy. CONCLUSIONS: Xiphodynia is a diagnostic conundrum, which is why reports on its treatment including surgical resection of the xiphoid are even sparser. So far, this is the largest reported series of surgically treated xiphodynia. Correct diagnosis remains the key factor for success. While tenderness over the tip of the xiphoid process combined with protrusion of the xiphoid with a xiphisternal angle of <160° are good indications for surgery, patients after previous operations affecting the xiphoid process are less likely to benefit from xiphoidectomy.

Heterotopic Ossification of the Xiphoid Process after Abdominal Surgery for Traumatic Hemoperitoneum.

Heterotopic ossification of the xiphoid process is extremely rare, with only three cases previously reported. However, the surgical pathology for postoperative elongation of the xiphoid process after abdominal surgery has not yet been reported. We report a case of the postoperative elongation of the xiphoid process, 8 years after abdominal surgery for traumatic hemoperitoneum in a 53-year-old man. The patient underwent surgical excision of the elongated mass of the xiphoid process. Histopathology revealed multiple exostoses. Heterotopic ossification can occur after surgical trauma to soft or bone tissue. Surgical excision with primary closure is the treatment of choice for symptomatic heterotopic ossification.

Identification of 4th intercostal space using sternal notch to xiphoid length for accurate electrocardiogram lead placement.

OBJECTIVE: Precordial ECG lead placement is difficult in obese patients with increased chest wall soft tissues due to inaccurate palpation of the intercostal spaces. We investigated whether the length of the sternum (distance between the sternal notch and xiphoid process) can accurately predict the location of the 4th intercostal space, which is the traditional location for V1 lead position. MATERIALS AND METHODS: Fifty-five consecutive adult chest computed tomography examinations were reviewed for measurements. RESULTS: The sternal notch to right 4th intercostal space distance was 67% of the sternal notch to xiphoid process length with an overall correlation of r=0.600 (p<0.001). CONCLUSION: The above measurement may be utilized to locate the 4th intercostal space for accurate placement of the precordial electrodes in adults in whom the 4th intercostal space cannot be found by physical exam.

Xiphodynia Mimicking Acute Coronary Syndrome.

A 79-year-old man with diabetes and partial gastrectomy visited our hospital due to gradually worsening epigastric pain on exertion. Unstable angina was suspected and coronary angiography was performed, which revealed severe stenosis of the left ascending artery. Despite successful intervention, the pain persisted. A careful physical examination finally revealed the point of tenderness on the xiphoid process, and the patient was diagnosed with xiphodynia. The severe epigastric pain resolved immediately after xiphoidectomy. This case demonstrates that symptoms of xiphodynia may mimic those of various types of disorders, such as angina, and that careful palpation is warranted during routine physical examinations.

Xiphoidectomy for xiphoid process-induced pain in a surfer.

A 53-year-old man who had been surfing for more than 30 years was referred to our hospital with upper abdominal wall pain. Computed tomography showed that his xiphoid process was protruding forward and the overlying skin was thickened. We diagnosed chronic abdominal wall pain due to repeated compression between the surfboard and his xiphoid process. To relieve the pain, we performed a xiphoidectomy. The pain resolved after surgery and he resumed surfing 26 days postoperatively. Xiphoidectomy is effective for treating xiphoid process-induced pain in surfers.

Sternal foramina: incidence in Greek population, anatomy and clinical considerations.

PURPOSE: Sternal foramina represent developmental defects in the sternum, which occur due to incomplete fusion of the sternal ossification centers. Sternal foramina have been correlated with several clinical implications and constitute a subject of interest for the forensic practice. The aim of this study is to define their incidence in Greek population. METHODS: The presence of midline foramen was studied in 60 dried, adult sterna derived from the Anatomy Department of Medical School of Aristotle University of Thessaloniki. Measurements were made with a 0.01-mm accuracy caliber and photographic documentation was obtained. Additionally, computed tomography scanning of the sterna was performed. RESULTS: Sternal foramina were found in 11 subjects, resulting in an incidence of 18.3% over the total population. In 27.3% of the subjects with sternal foramen, a single sternal foramen was observed in the body of the sternum, while in 45.5% of the sterna presenting sternal foramina, multiple xiphoidal foramina were noticed. In two specimens, association of xiphoidal foramina with sternal cleft was documented. CONCLUSION: Sternal foramina are variant quite common in the population, with distinct imaging pattern and awareness of their existence is important for the physician.

Intentional right atrial exit for microcatheter infusion of pericardial carbon dioxide or iodinated contrast to facilitate sub-xiphoid access.

OBJECTIVES: We test the safety of transatrial pericardial access using small catheters, infusion of carbon dioxide (CO2 ) or iodinated contrast to facilitate sub-xiphoid access, and catheter withdrawal under full anticoagulation. BACKGROUND: Sub-xiphoid pericardial access is required for electrophysiological and structural heart interventions. If present, an effusion protects the heart from needle injury by separating the myocardium from the pericardium. However, if the pericardium is 'dry' then there is a significant risk of right ventricle or coronary artery laceration caused by the heart beating against the needle tip. Intentional right atrial exit is an alternative pericardial access route, through which contrast media could be infused to separate pericardial layers. METHODS: Transatrial pericardial access was obtained in a total of 30 Yorkshire swine using 4Fr or 2.8Fr catheters. In 16 animals, transatrial catheters were withdrawn under anticoagulation and MRI was performed to monitor for pericardial hemorrhage. In 14 animals, iodinated contrast or CO2 was infused before sub-xiphoid access was obtained. RESULTS: Small effusions (mean 18.5 ml) were observed after 4Fr (1.3 mm outer-diameter) but not after 2.8Fr (0.9 mm outer-diameter) transatrial catheter withdrawal despite full anticoagulation (mean activated clotting time 383 sec), with no hemodynamic compromise. Pericardial CO2 resorbed spontaneously within 15 min. CONCLUSIONS: Intentional transatrial exit into the pericardium using small catheters is safe and permits infusion of CO2 or iodinated contrast to separate pericardial layers and facilitate sub-xiphoid access. This reduces the risk of right ventricular or coronary artery laceration. 2.8Fr transatrial catheter withdrawal does not cause any pericardial hemorrhage, even under full anticoagulation.

Frequency of sternal foramen evaluated by MDCT: a minor variation of great relevance.

Due to inadvertent cardiac or great vessel injury, sternal foramina may pose as a great hazard during sternal puncture. They can also be misinterpreted as osteolytic lesions in cross-sectional imaging of the sternum. The distribution of these variations differs between populations, but data from Brazilians are scarcely reported. Therefore, this study aimed to verify the frequency of midline sternal foramen and double-ended xiphoid process, as developmental variations, in order to avoid fatal complications following sternal puncture of sternal acupuncture treatment. A total of 114 chest computed tomograms were evaluated. The frequency of midline sternal foramen in a complication risk bearing feature is of approximately 10.5%. The double-ended xiphoid process was present in 17.5%. We conclude that sternal acupuncture should be planned in the region of corpus-previous CT should be done to rule out this variation. Furthermore, we strongly recommend the acupuncture technique which prescribes a safe superficial-oblique approach to the sternum.

Nasogastric tube depth: the 'NEX' guideline is incorrect.

Misplacing 17-23% of nasogastric (NG) tubes above the stomach ( Rollins et al, 2012 ; Rayner, 2013 ) represents a serious risk in terms of aspiration, further invasive (tube) procedures, irradiation from failed X-ray confirmation, delay to feed and medication. One causal factor is that in the National Patient Safety Agency (NPSA) guidance to place a tube, length is measured from nose to ear to xiphisternum (NEX) ( NSPA, 2011 ); NEX is incorrect because it only approximates the nose to gastro-oesophageal junction (GOJ) distance and is therefore too short. To overcome this and because the xiphisternum is more difficult to locate, local policy is to measure in the opposite direction; xiphisternum to ear to nose (XEN), then add 10 cm. The authors determined whether external body measurements can be used to estimate the NG tube length to safely reach the gastric body. This involved testing the statistical association of body length, age, sex and XEN in consecutive critically ill patients against internal anatomical landmarks determined from an electromagnetic (EM) trace of the tube path. XEN averaged 50 cm in 71 critically ill patients aged 53±20 years. Tube marking and the EM trace were used to determine mean insertion distances at pre-gastro-oesophageal junction (GOJ) (48 cm), where the tube first turns left towards the stomach and becomes shallow on the trace; gastric body (62 cm), where the tube reaches the left-most part of the stomach; and gastric antrum (73 cm) at the midline on the EM trace. Using body length, age, sex and XEN in a linear regression model, only 25% of variability was predicted, showing that external measurements cannot reliably predict the length of tube required to reach the stomach. A tube length of XEN (or NEX) is too short to guarantee gastric placement and is unsafe. XEN+10 cm or more complex measurements will reach the gastric body (mid-stomach) in most patients, but because of wide variation, external measurements often fail to predict a safe distance. Only the EM trace or possibly direct vision can show in real time whether the tip has safely reached the gastric body.

Xiphoid syndrome: an uncommon occupational disorder.

We report a case of a 45-year-old man, complaining of swelling and pain in his epigastric region for the last 3 years. According to his medical history, he had undergone various investigations and treatments for gastro-oesophageal reflux, without relief. He had had a history of chronic repeated microtraumas to his sternum during 9 years of working as a carpenter, as a result of placing wood against his anterior chest wall and pushing the former into a plank cutting machine. On examination, a tender swelling was palpable as an immobile, hard mass showing minimal protrusion under the skin on the xiphoid process. He was diagnosed as having xiphoid syndrome. We prescribed anti-inflammatory medication and advised him to avoid pressure on his anterior chest wall, especially on the sternum, while cutting wood. At follow-up, the symptoms were relieved. Xiphoid syndrome may be seen in people performing hard physical work who incur sustained pressure or friction on their anterior chest wall. The case emphasizes the importance of the occupational history as well as clinical and radiological investigation of unusual conditions as mentioned above.

Morphology of the human xiphoid process: dissection and radiography of cadavers and MDCT of patients.

PURPOSE: The purpose of this study was to evaluate the morphology of xiphoid process by dissection and using radiography of cadavers and multidetector computed tomography (MDCT) in patients. METHODS: The xiphoid processes of 41 cadavers were dissected and taken by radiography. Other 902 patients examined by MDCT were revealed by image post-processing used with multiple planar reconstruction, maximum intensity projection and volume rendering. RESULTS: Xiphoid processes displayed pointed shape in 422 cases (44.75 %), oval shape in 387 cases (41.04 %), and forked shape in 134 cases (14.21 %). The sagittal shape of the xiphoid process was observed as ventrally deviated in 217 cases (23.01 %), dorsally deviated in 191 cases (20.25 %), S-shaped (ahead ventral, then dorsal) in 21 cases (2.23 %), and resembling a hook in 14 of ventral deviated patients and in 19 of those dorsal deviated patients. The foramen of xiphoid processes was found in 544 cases (57.69 %). The pattern L (a large foramen with a diameter of more than 5 mm) appeared in 302 cases (55.51 %), pattern S (a small foramen with a diameter of no more than 5 mm) in 155 cases (28.49 %), pattern LS (a mixture of a large and a small foramina) in 37 cases (6.80 %), and pattern SS (two or more small foramina) in 50 cases (9.19 %). CONCLUSION: Human xiphoid process appeared in morphological diversity. The anatomic structure and ossification degree of xiphoid process was well evaluated by MDCT. Our data may be used for diagnosis and surgical treatment of xiphoid process-related diseases.