The quality of published paediatric audits and their standards.

OBJECTIVE: Audit is a recognised tool for evaluating the performance and improving the quality of health services. In Ireland and the UK, clear resources are available outlining audit elements. This study was undertaken to evaluate paediatric audits published from 2007 to 2020 to determine the adherence level to the definition of audit and to assess the quality of audit standards. DESIGN: PUBMED, MEDLINE and CINAHL databases were searched to identify relevant articles published in the English language. Each was reviewed to assess whether the following criteria were met: (1) a paediatric healthcare topic was described, (2) practice was reviewed, (3) the standard was specified, (4) an intervention was made and data collection was repeated to assess improvement. The quality of the standard for each true audit was graded utilising the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS: Of 1230 published paediatric healthcare articles reviewed, 144 (11.4%) fulfilled the full criteria of an audit. Sixty-three (43.8%) true audits used the highest quality of evidence (level 1a and 1b), predominantly international or national guidelines. Fifty-six (38.9%) audits used the lowest quality of evidence (level 5), predominantly expert opinion. CONCLUSIONS: There is a mismatch between the common usage of the term audit, and the definition, despite its incorporation into training curricula and institutional support. Many articles published as audits do not adhere to the definition of audit. There are variable levels of evidence supporting the standards utilised in published true audits.

Gastric Point-of-Care Ultrasound in Acutely and Critically Ill Children (POCUS-ped): A Scoping Review.

Introduction: Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children. Materials and Methods: An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute). Results: A total of 70 studies were included. Most studies (n = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion (n = 6), nasogastric tube placement (n = 5), hypertrophic pyloric stenosis (n = 8), and gastric insufflation during mechanical ventilatory support (n = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms. Discussion: Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation.

Planned Peri-Extubation Fasting in Critically Ill Children: An International Survey of Practice.

Introduction: Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them. Materials and Methods: A cross sectional electronic survey was disseminated via the European Pediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation. Results: We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice: 46 (38%) and 26 (21%) of PICUs withheld oral and gastric/jejunal nutrition more than 5 h, respectively, and 45 (37%) started oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children [78 (64%)] or reducing fasting times [57 (47%)] respectively. Discussion: This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it.

Successful Management of a COVID-19 Positive Infant With Transposition of the Great Arteries.

A six-week-old infant presented in extremis and was diagnosed with dextro-transposition of the great arteries, intact ventricular septum, features of left ventricular deconditioning, and abnormal coronary arteries. Treatment with prostaglandin E1 and balloon atrial septostomy was insufficient, necessitating extracorporeal membrane oxygenation (ECMO). Severe acute respiratory syndrome coronavirus-2 was detected. The arterial switch operation was delayed by eight days because of COVID-19. Although stable on ECMO, the infant was treated with remdesivir. Extracorporeal membrane oxygenation was not required postoperatively with chest closure on day 2 and extubation on day 5.

Non-intercostal access for video-assisted thoracic surgery-analysis of technical advantages and disadvantages.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted method for the treatment of early-stage non-small-cell lung cancer (NSCLC). The standard VATS approach is an intercostal one which is often followed by postoperative pain due to injury of the intercostal nerve. The non-intercostal techniques of VATS include the subxiphoid, transcervical, transdiaphragmatic and transoral procedures. METHODS: The technical difficulty of operative management of the anatomical structures during VATS anatomical resection are compared for the intercostal, subxiphoid and transcervical approaches. RESULTS: Some operative steps have different range of difficulty, which are analyzed in detail. CONCLUSIONS: The clearest advantages of the non-intercostal approaches include less postoperative pain and superradial bilateral mediastinal lymphadenectomy in case of the transcervical approach. However, the non-intercostal approaches are more technically demanding procedures, which therapeutic role has to be clarified in the future.

Transcervical uniportal pulmonary lobectomy.

BACKGROUND: The aim of the study is a description of surgical technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy. METHODS: We used a collar neck incision (transcervical) of an average length 5-8 centimeters. The manubrium of the sternum is elevated with a hook connected to the Zakopane II frame (Aesculap-Chifa, B. Braun, Nowy Tomysl, Poland). The first step is a transcervical extended mediastinal lymphadenectomy (TEMLA), for improved staging and possible improved survival. The nodes removed during TEMLA undergo intraoperative imprint cytology examination. In case of no metastasis a uniportal VATS lobectomy through the neck follows. Ventilation of the operated lung is disconnected and the pleural cavity is entered by opening of the mediastinal pleura. Pleural adhesions, if present are managed with electrocautery. The branches of the pulmonary artery and vein are sequentially dissected and managed with endostaplers or vascular clips. The lobar bronchus and the fissures are divided with endostaplers and the resected lobe is removed in an endobag. RESULTS: There were 16 patients operated on in the period 1.2.2016-30.7.2016. There were two conversions-in one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. In the other patient undergoing right lower lobectomy there was a conversion to right thoracotomy because of the bleeding from the pulmonary artery. There was no mortality and complications occurred in three patients. The mean operative time was 245.6 min (range, 145-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 175.6 min (range, 75-295 min) for a lobectomy solely. CONCLUSIONS: A uniportal transcervical VATS approach for pulmonary lobectomy combined with transcervical extended mediastinal lobectomy (TEMLA) provides an opportunity for radical pulmonary resection and superradical extensive mediastinal lymphadenectomy.

The Zakopane Pulmonary Hospital experience on subxiphoid thymectomy.

BACKGROUND: To present the technique of minimally invasive extended thymectomy performed through the subxiphoid-bilateral subcostal video-assisted thoracoscopic surgery (VATS) approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS: The whole dissection was performed through the 4-7 cm transverse subxiphoid incision with single 10 mm extra-long bariatric laparoscopy ports inserted subcostally to the right and left chest cavities for videothoracoscope and subsequently for chest tubes. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. RESULTS: There were 147 patients (62 patients operated on for thymomas, 75 patients for nonthymomatous MG and 10 for rethymectomies) in the period 1.1.2009-30.3.2016. There was no mortality and morbidity. The mean operative time was 109.1 min (range, 75-150 min). CONCLUSIONS: The subxiphoid approach combined with bilateral single port subcostal VATS and double elevation of the sternum enables very extensive thymectomy in case of nonthymomayous MG.

Uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA).

BACKGROUND: To present the technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lymphadenectomy (TEMLA). METHODS: Transcervical extended approach utilizes a typical a 5-8 centimeters collar incision in the neck. The critical technical point enabling a wide access to the chest is an elevation of the sternal manubrium with a special retractor (modified Rochard frame, Asculap-Chifa Company). A bilateral visualization of the laryngeal recurrent and vagus nerves is usually performed to avoid injury of these structures. The uniportal transcervical VATS lobectomy for NSCLC is preceded by TEMLA to enable optimal intraoperative staging of the mediastinal nodes and perform extensive bilateral lymphadenectomy, which theoretically might affect survival. VATS lobectomy is the next step after obtaining results of intraoperative examination of the nodes. Ventilation of the operated lung is disconnected and the mediastinal pleura is opened. Pleural adhesions are divided. The branches of the pulmonary artery and vein and the lobar bronchus are sequentially dissected and managed with endo staplers. The fissure is divided with endo stapler and the resected lobe is removed in endobag. RESULTS: There were 9 patients operated on in the period 1.2.2016-30.7.2016. In one patient with left lower lobe tumor we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. There was no mortality and complications occurred in 2 patients. The mean operative time was 258.1 min (200-385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 168.1 min (110-295 min) for a lobectomy solely. CONCLUSIONS: A uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with TEMLA provides an opportunity for radical pulmonary resection and super radical extensive mediastinal lymphadenectomy.

Subxiphoid uniportal VATS thymectomy.

BACKGROUND: To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS: Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. RESULTS: There were four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity. CONCLUSIONS: The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.

Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum.

OBJECTIVES: To present the new technique of minimally invasive extended thymectomy performed through the subxiphoid-right video-thoracoscopic (VATS) approach with double elevation of the sternum and the early results of resection of thymomas with the use of this technique. OPERATIVE TECHNIQUE: whole dissection was performed through a 4- to 7-cm transverse subxiphoid incision, and a single 5-mm port was inserted into the right chest cavity for the video thoracoscope and subsequently for the chest tube. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision, and the superior hook was inserted percutaneously after the mediastinal tissue including the major mediastinal vessels was dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. RESULTS: There were 24 patients operated on for the Masaoka Stage I-III thymoma in the period from 1 January 2009 to 30 March 2012. There was no mortality and complications occurred in 1 patient necessitating revision for bleeding (morbidity rate 4.2%). The median operative time was 105.0 (range 70-195) min. In 2 patients it was possible to completely resect Masaoka Stage III tumour infiltrating the right lung, which was resected with the use of an endostapler. The dimensions of the thymomas ranged from 1.8 × 1.5 × 1.5 to 12 × 9 × 5 cm. CONCLUSIONS: In our opinion, the presented technique is probably the least invasive and the most complete technique of VATS thymectomy with excellent cosmetic results and is a valid alternative to sternotomy approach for the Masaoka Stage I-III thymomas.

[Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) for staging of non-small-cell lung cancer (NSCLC)]. / TEMLA--rozszerzone wyciecie wezlów chlonnych sródpiersia w diagnostyce niedrobnokomórkowego raka pluca.

INTRODUCTION: The aim of the study is to analyze diagnostic yield of the new surgical technique--the Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) in preoperative staging of Non-Small-Cell Lung Cancer (NSCLC). MATERIAL AND METHODS: Operative technique included 5-8 cm collar incision in the neck, elevation of the sternal manubrium with a special retractor, bilateral visualization of the laryngeal recurrent and vagus nerves and dissection of all mediastinal nodal stations except of the pulmonary ligament nodes (station 9). RESULTS: 698 patients (577 men, 121 women), of mean age 62.8 (41-79) were operated on from 1.1.2004 to 31.1.2010, including 501 squamous-cell carcinomas, 144 adenocarcinomas, 25 large cell carcinomas and 28 others. Mean operative time was 128 min. (45 to 330 min) and 106.5 min. in the last 100 patients. 30-day mortality was 0.7 % (unrelated causes) and morbidity 6.6%. The mean number of dissected nodes during TEMLA was 37.9 (15 to 85). Metastatic N2 and N3 nodes were found in 152/698 (21.8%) and 26/698 patients (3.7%), respectively. Subsequent thoracotomy was performed in 445/513 patients (86.7%) after negative result of TEMLA. During thoracotomy, omitted N2 was found in 7/445 (1.6%) patients. Sensitivity of TEMLA in discovery of metastatic N2-3 nodes was 96.2 %, specificity was 100%, accuracy was 99,0%, Negative Predictive Value (NPV) was 98.7 % and Positive Predictive Value (PPV) was 100%. CONCLUSIONS: TEMLA is a new minimally invasive surgical procedure providing unique possibility to perform very extensive, bilateral mediastinal lymphadenectomy with very high diagnostic yield in staging of NSCLC Pneumonol.

Comparison of complete remission rates after 5 year follow-up of three different techniques of thymectomy for myasthenia gravis.

OBJECTIVE: This study aims to analyse the effectiveness of treatment of myasthenia gravis with three different techniques of thymectomy. METHODS: Results of complete remission rates after 5-year follow-up of 60 patients who underwent basic transsternal thymectomies (group A) from 1 January 1996 to 31 December 1997, 75 patients who underwent extended transsternal thymectomies (group B) from 1 January 1998 to 30 June 2000 and 291 patients who underwent transcervical-subxiphoid-videothoracoscopic 'maximal' thymectomy (group C) from 1 September 2000 to 31 January 2009 were compared. RESULTS: There were no differences between groups according to patient's characteristics and postoperative complications' rate. Ectopic foci of the thymic tissue were discovered in the fat of the neck and the mediastinum in 53.9% of patients from the group B and in 65.9% patients from the group C. After 1, 2, 3, 4 and 5 years of follow-up, complete remission rates were 8.3%, 11.7%, 15.0%, 16.7% and 20.0%, respectively, in group A; 26.7%, 38.7%, 42.7%, 46.7% and 50.7%, respectively, in group B; and 31.5%, 39%, 45.8%, 46.3% and 53.1%, respectively, in group C. The differences between group A and the groups B and C after 1, 2, 3, 4 and 5 years were statistically significant. There were no significant differences between groups B and C. CONCLUSIONS: (1) The results of complete remission rates after 5-year follow-up were statistically better in patients with myasthenia gravis (MG), who were operated on with extended transsternal thymectomy and transcervical-subxiphoid-videothoracoscopic 'maximal' thymectomy than the patients who underwent basic transsternal thymectomy. (2) The difference can be explained by the removal of ectopic foci of the thymic tissue from the neck and the mediastinum in these patients.

Non-small-cell lung cancer restaging with transcervical extended mediastinal lymphadenectomy.

BACKGROUND: To analyse a diagnostic yield of the transcervical extended mediastinal lymphadenectomy (TEMLA) in restaging of the mediastinal nodes after neoadjuvant chemo- or chemo-radiotherapy for non-small-cell lung cancer (NSCLC). METHODS: From 1 January 2004 to 30 April 2009, 63 patients who underwent induction chemotherapy or chemo-radiotherapy for N2 and N2/3 metastatic nodes discovered preoperatively were restaged. There were 12 women and 51 men in the age group of 43-71 (mean 57.8) years. There were 45 squamous cell carcinomas, 13 adenocarcinomas, one pleomorphic carcinoma and four NSCLCs. A total of 54 patients underwent neoadjuvant chemotherapy and nine chemo-radiotherapy. Seven patients had mediastinoscopy before neoadjuvant therapy. As many as 34 patients underwent endobronchial ultrasound (EBUS), one patient underwent endo-oesophageal ultrasound (EUS) and 10 patients underwent combined EBUS/EUS. The diagnostic results of TEMLA were compared with the results of the largest published series of restaging patients. The results of subsequent thoracotomies after negative TEMLA were presented. RESULTS: There were no serious complications or mortality after TEMLA. Metastatic nodes were discovered in 22 patients including three patients with N3 nodes and 19 patients with N2 nodes. Stations 7, 4R, 2R and 4L were the most prevalent. Of the 63 patients, 42 underwent subsequently thoracotomy. Resectability for negative TEMLA was 92.7%. There were 37 R0 resections and four R1 resections. There was no postoperative mortality, two bronchial fistulas were developed (after inferior bilobectomy and right pneumonectomy; the second one healed spontaneously) and there were no other serious complications. During thoracotomy with completion lymphadenectomy one false-negative result was found (single node in station 8). Sensitivity of TEMLA in the discovery of N2/3 nodes during restaging was 95.5%, specificity 100%, accuracy 98.3%, negative predictive value (NPV) 97.4% and positive predictive value (PPV) 100%. TEMLA was found to have significantly better sensitivity and NPV (p<0.05) than other series of restaging. During follow-up a local recurrence was noted in six of 37 (15.7%) patients after pulmonary resection. CONCLUSIONS: (1) The results of TEMLA in restaging of NSCLC (N2/3) patients after induction chemotherapy or chemo-radiotherapy were significantly better than those achieved with remediastinoscopy, EBUS and positron emission tomography/computed tomography (PET/CT). (2) The results of future studies will show if TEMLA should be considered the gold standard of mediastinal nodal restaging after neoadjuvant therapy in patients with NSCLC.

Staging algorithm for diffuse malignant pleural mesothelioma.

An algorithm of preoperative mediastinal nodal staging with endobronchial/endoesophageal ultrasonography (EBUS/EUS) and transcervical extended mediastinal lymphadenectomy (TEMLA) combined with laparoscopy/peritoneal lavage and cytology was analyzed to establish the realistic criteria for radical multimodality treatment of malignant pleural mesothelioma (MPM). The algorithm included computed tomography (CT), thoracoscopy with multiple pleural biopsies and talc pleurodesis, EBUS/EUS and one-stage TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid. Forty-two patients were diagnosed from 1 January 2004 to 31 December 2008. There were 16 women and 26 men in ages ranging from 43 to 77 years (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. Three patients who received neoadjuvant chemotherapy were excluded from this study. EBUS/EUS was performed to stage the mediastinal nodes. In 3/18 patients metastatic nodes were discovered. In the rest of the 15 patients simultaneous TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid were performed. In three patients TEMLA was positive, in six patients laparoscopy was positive and in two patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with one exploration (chest wall infiltration) and three pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery.

The right upper lobe pulmonary resection performed through the transcervical approach.

OBJECTIVE: Preliminary report: presentation of the new technique of transcervical right upper lobectomy with transcervical extended mediastinal lymphadenectomy (TEMLA) for NSCLC. METHODS: Two patients underwent the operation that was performed through the collar incision, with elevation of the sternal manubrium with the mechanical sternal retractor. TEMLA and bilateral mediastinal lymph node excision (stations 1, 2R, 4R, 2L, 4L, 3A, 3P, 7 and 8) and bilateral supraclavicular lymph node excision were performed (frozen section analysis: all nodes negative). The mediastinal pleura was opened and the following structures were dissected in the open fashion with standard surgical instruments and divided with the use of endostaplers: the azygos vein, the upper trunk of the right pulmonary artery, the branch of the superior pulmonary vein to the upper lobe, the upper lobe bronchus, the segment 2 artery, the posterior part of the oblique fissure and the horizontal fissure. The operation was performed with the use of one videothoracoscopic (VTS) port for insertion of 5mm, 30 degree VTS camera for intraoperative control and for single thoracic drain for the postoperative period. RESULTS: The operative times were 250 and 270 min, respectively; intraoperative blood loss was 110 and 100ml, respectively. There were no intraoperative complications. The postoperative course was remarkably smooth. The final pathologic report: large cell carcinoma pT2N0M0 and squamous cell carcinoma pT2N0M0, no metastatic changes of 51 and 41 mediastinal and intrapulmonary (stations 10, 11 and 12) and supraclavicular nodes, respectively. CONCLUSIONS: This preliminary report indicates possible advantages of the transcervical right upper lobe pulmonary resection including: (1) extremely radical, minimal invasive procedure with no need for utility thoracotomy; (2) dissection performed with standard surgical instruments in the open fashion.

Technique of the transcervical-subxiphoid-videothoracoscopic maximal thymectomy.

BACKGROUND: The aim of this study is to present the new technique of transcervical-subxiphoid-videothoracoscopic "maximal"thymectomy introduced by the authors of this study for myasthenia gravis. MATERIALS AND METHODS: Two hundred and sixteen patients with Osserman scores ranging from I-III were operated on from 1/9/2000 to 31/12/2006 for this study. The operation was performed through four incisions: a transverse 5-8 cm incision in the neck, a 4-6 cm subxiphoid incision and two 1 cm incisions for videothoracoscopic (VTS) ports. The cervical part of the procedure was performed with an open technique while the intrathoracic part was performed using a video assisted thoracoscopic surgical (VATS) technique. The whole thymus with the surrounding fatty tissue containing possible ectopic foci of the thymic tissue was removed. Such an operation can be performed by one surgical team (the one team approach) or by two teams working simultaneously (two team approach). The early and late results as well as the incidence and localization of ectopic thymic foci have been presented in this report. RESULTS: There were 216 patients in this study of which 178 were women and 38 were men. The ages of the patients ranged from 11 to 69 years (mean 29.7 years). The duration of myasthenia was 2-180 months (mean 28.3 months). Osserman scores were in the range of I-III. Almost 27% of the patients were taking steroids or immunosuppressive drugs preoperatively. The mean operative time was 201.5 min (120-330 min) for a one-team approach and it was 146 (95-210 min) for a two-team approach (P < 0.05). While there was no postoperative mortality, the postoperative morbidity was 12%. The incidence of ectopic thymic foci was 68.4%. The rates of complete remission after one, two, three, four and five years of follow-up were 26.3, 36.5, 42.9, 46.8 and 50.2%, respectively. CONCLUSION: Transcervical-subxiphoid-VTS maximal thymectomy is a complete and highly effective treatment modality for myasthenia gravis. The need for sternotomy is avoided while the completeness of the operation is retained.

Transcervical extended mediastinal lymphadenectomy.

Transcervical extended mediastinal lymphadenectomy (TEMLA) is a new procedure for bilateral excision of all nodal stations of the mediastinum, except for the pulmonary ligament nodes (station 9) and the most distal left lower paratracheal nodes (station 4L). The procedure is performed through a transverse 5-8 cm incision in the neck with elevation of the sternum with a traction device facilitating the access to the mediastinum. Most of the procedure is performed with an open technique, while the removal of the subcarinal (station 7) and periesophageal nodes (station 8) is performed with the mediastinoscopy assisted technique and excision of the paraaortic nodes (station 6), the aorta-pulmonary window nodes (station 5) and, sometimes, the prevascular nodes (station 3A) is performed with the aid of a videothoracoscope introduced to the mediastinum through the neck incision, without violating the pleura.

Transcervical extended mediastinal lymphadenectomy--the new operative technique and early results in lung cancer staging.

OBJECTIVE: Mediastinal staging is one of the most important problems in thoracic surgery. Although the pathological examination is a generally accepted standard, none of the currently used techniques enables complete removal of all lymph node stations of the mediastinum. The aim of the study is to present a new technique of transcervical extended mediastinal lymphadenctomy (TEMLA) and to analyze its value in lung cancer staging. METHODS: In the prospective study of consecutive group of non-small cell lung cancer (NSCLC) patients, operated on between January and August 2004, we evaluated the usefulness of this original technique of bilateral mediastinal lymphadenectomy, assessing its accuracy and safety. The operations were performed through the transcervical approach, were videomediastinoscopy-assisted, with sternum elevation. Lymph node stations 1, 2R, 2L, 3a, 4R, 4L, 5, 6, 7 and 8 were removed. In patients without mediastinal metastases thoracotomy with pulmonary resection was performed and mediastinum searched for any missed lymph nodes. RESULTS: There were 83 patients operated on with the TEMLA technique. The mean number of nodes removed was 43 (range: 26-85). The sensitivity, specificity and accuracy of the presented method in detecting mediastinal node metastases were: 90, 100, and 96%, respectively, whereas the positive and negative predictive values were: 100 and 95%, respectively. CONCLUSIONS: The TEMLA technique is a safe and highly accurate method of mediastinal staging in NSCLC.