[Surgery for complicated accessory lobe of the azygos vein]. / Khirurgiya oslozhnennoi dobavochnoi doli neparnoi veny.

Congenital anomalies of respiratory system are quite diverse and not all of them are subject to surgical treatment. One example is accessory lobe of the azygos vein. This anomaly usually has no clinical manifestations and requires only follow-up, as well as attention in surgery on the right half of the chest for some other disease. This situation changes when complications occur, for example, purulent-inflammatory process. Therapy is not always effective, and lung tissue destruction requires surgical treatment. Progressive destruction complicates diagnosis and choosing surgical tactics. We present a rare case of severe purulent-inflammatory complication with abscess in accessory lobe of v. azygos. Anatomical abnormalities following this congenital pulmonary anomaly can cause difficulties in surgeries for other intra-thoracic diseases. The situation is especially relevant for thoracoscopic access. This report will be useful for radiologists, pulmonologists and thoracic surgeons.

A revamped MIC-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk.

BACKGROUND: The purpose of this study was to investigate the effect of our revamped MIE-McKeown operation on postoperative gastrointestinal function recovery. METHODS: This revamped MIE-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk and with the tubular stomach buried throughout esophageal bed and azygos arch, has been implemented from July 2020 to July 2021 by the same medical team of Gaozhou People's Hospital thoracic surgery for 13 times. Preoperative clinical data, main intraoperative indicators and postoperative complications were observed. RESULTS: All patients had esophageal malignant tumors at the level of middle and lower thoracic non-azygous venous arch, with preoperative clinical stage CT1-2N0M0 stage i-ii. V-vst test was performed on the 7th postoperative day, and 10 patients were found to have no loss of safety/efficacy. There were 2 cases with impaired efficacy and no impaired safety, 1 case with impaired safety. There were 1 cases of pulmonary infection, 1 cases of anastomotic fistula combined with pleural and gastric fistula, 2 cases of hoarseness, 2 cases of arrhythmia, 10 cases of swallowing function were grade i, 2 cases of swallowing function were grade iii, 1 case of swallowing function was grade iv in watian drinking water test one month after operation. CONCLUSIONS: Merit of this revamped MIE-McKeown operation is well preserving the integrity of azygos arch of vagus nerve and bronchial artery, and it is technically safe and feasible. No postoperative mechanical obstruction of thoracostomach, huge thoracostomach and gastrointestinal dysfunction occurs.

Staged approach for correction of anomalous venous return to the azygos vein.

Partial anomalous pulmonary venous return into the azygous vein is a rare pathological finding. We describe the case of a 28-year-old girl who had a successful staged approach to treat this rare congenital heart disease. To avoid potential connection of a systemic venous return to the left atrium, the proximal part of the azygous vein was occluded with a percutaneous approach, then the azygous vein flow was redirected into the left atrium with a surgical procedure.

Thoracoscopic AF ablation in situs inversus dextrocardia with interrupted inferior vena cava continuation in azygos vein.

INTRODUCTION: Situs inversus totalis, dextrocardia with interrupted inferior vena cava, and azygos vein continuation concomitant with symptomatic atrial fibrillation requiring ablation. This case was deemed not suitable for percutaneous ablation due to anatomic variations and the lack of case reports in the literature. METHODS AND RESULTS: We performed bilateral thoracoscopic epicardial ablation and epicardial left atrial appendage exclusion. The direct vision allowed for a complete box lesion set with bipolar radiofrequency device. Patient remained in sinus rhythm at the 12-months follow-up. CONCLUSION: Surgical thoracoscopic epicardial ablation is safe and effective also in congenital defects. Multidisciplinary expertise can offer minimally invasive ablation treatments.

Balloon atrial septostomy through azygos vein in two cases of D-TGA with left atrial isomerism.

Balloon atrial septostomy is a palliative procedure that is performed in D-transposition of great arteries when surgery is not immediately available. Although D-TGA and left isomerism association are rare, it is an important condition as the BAS procedure approach is unique. In this case report, we present two cases of D-TGA with left isomerism where BAS was performed due to restrictive atrial septal defect and lack of immediate availability of the paediatric cardiac surgeon.

Refractory Chylothorax Secondary to Sizeable Azygos Vein Hemangioma: Tailored Multimodal Treatment of a Challenging Case Report.

BACKGROUND: Mediastinal hemangiomas are rare, and their etiology remains unclear. Most patients affected have no pathognomonic clinical symptoms, and the diagnosis is often incidental. Due to the paucity of the available literature regarding the management of this disease, the choice and timing of treatment remains controversial. CASE PRESENTATION: Herein, we report the case of a hemangioma of the azygos vein arch in a 66-year-old woman who presented with dyspnea, chest discomfort, dysphagia, and weight loss. A simultaneous right chylothorax refractory to conservative management was found. A CT-guided biopsy of the mass was performed, and it confirmed the vascular nature of the lesion. Therefore, the patient underwent an angiography followed by endo-vascular embolization. Three days later, thoracoscopic surgical resection of the mass and the repair of the chyle leakage were performed safely. The patient was discharged uneventfully on postoperative day seven, with complete resolution of all the presenting symptoms. CONCLUSIONS: Treatment of symptomatic mediastinal hemangiomas could be mandatory, but a thorough multidisciplinary approach to these rare malformations is essential. Despite the risk of intraoperative bleeding, selective endovascular embolization followed by thoracoscopic surgery allowed for a complete and safe resection with a good outcome.

Modified (Bai-Jiang style) vagus nerve-preserving versus conventional laparoscopic splenectomy and azygoportal disconnection: a randomized clinical trial.

BACKGROUND: Digestive system complications are among the most important causes of postoperative poor quality of life after open and conventional laparoscopic splenectomy and azygoportal disconnection (CLSD). We firstly developed a modified vagus nerve-preserving laparoscopic splenectomy and azygoportal disconnection (MVLSD). In this study, we aimed to evaluate whether MVLSD is feasible and safe and to determine whether MVLSD can effectively eliminate postoperative digestive system complications, in comparison with CLSD. METHOD: In this randomized controlled single-center study, 60 patients with cirrhosis were randomly assigned to undergo either CLSD (n = 30) or MVLSD (n = 30) between April and December 2018. The primary outcome was delayed gastric emptying (DGE). Endoscopic physicians were blinded to group assignments. RESULTS: One patient who received MVLSD withdrew from the study. There were no significant differences in intraoperative blood loss, incidence of blood transfusion, time to off-bed activity, time to first flatus, and postoperative hospital stay between the two groups. Compared with CLSD, operation time and incidences of DGE, diarrhea, epigastric fullness, and overall postoperative complications were all significantly reduced in the MVLSD group (all P < 0.05). Compared with CLSD, MVLSD was associated with significantly increased weight and albumin levels at 1, 6, and 12 months postoperatively versus preoperative values (all P < 0.05). The curative effect of resolving gastroesophageal variceal bleeding was similar between the groups. CONCLUSION: MVLSD is not only a technically feasible and safe procedure, it is also succinct and convenient. Furthermore, MVLSD effectively reduces postoperative digestive system complications, contributing to improved quality of life.

Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

BACKGROUND: Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS). METHODS: This prospective, randomized, patient-blinded, single-institution trial was registered at the University Hospital Medical Information Network (UMIN000030464). Enrolled patients had been scheduled for VATS under general anesthesia with epidural analgesia. Patients were randomly allocated to receive infiltration of the ipsilateral phrenic nerve at the azygos vein level with either 10 mL of 0.375% ropivacaine (PNB group) or 0.9% saline (control group) before chest closure. Postoperative ISP was assessed using a numerical rating scale (NRS, 0-10) at rest at 2, 4, 8, 16, and 24 hours. The incidence of ISP was defined as the proportion of patients who reported an NRS score of ≥1 at least once within 24 hours after surgery. In the primary analysis, the proportion of patients with ISP was compared between PNB and control groups using the χ2 test. NRS values of ISP and postoperative incision pain within 24 hours were investigated, as was the frequency of postoperative analgesic use. Incision pain was assessed using an NRS at the time of ISP assessment. Finally, the incidence of postoperative nausea and vomiting and shoulder movement disorders were also evaluated. RESULTS: Eighty-five patients were included, and their data were analyzed. These patients were randomly assigned to either PNB group (n = 42) or control group (n = 43). There were no clinically relevant differences in demographic and surgical profiles between the groups. There was no significant difference in the incidence of ISP (the control group 20/43 [46.5%] versus the PNB group 14/42 [33.3%]; P = .215). The severity of ISP was lower in the PNB group than in the control group (linear mixed-effects model, the main effect of treatment [groups]: P < .001). There were no significant differences between groups in terms of postoperative incision pain. The frequency of postoperative analgesic use was significantly higher in the control group (Wilcoxon rank sum test, P < .001). Postoperative nausea and vomiting did not significantly differ between the 2 groups. There were no changes in the range of shoulder joint movement. CONCLUSIONS: Azygos vein level PNB did not significantly affect the incidence of ISP after VATS.

Totally endoscopic atrial septal defect repair in a patient with interrupted inferior vena cava with azygos-hemiazygos continuation.

Atrial septal defect combined with interrupted inferior vena cava (IVC), which is a rare condition, makes it impossible to apply totally endoscopic surgery (TES). The most difficulty is how to drain blood from the posthepatic segment of the IVC. In this study, we report a case of a 44-year-old female patient who was diagnosed with secundum atrial septal defect combined with interrupted IVC with azygos-hemiazygos continuation. This patient underwent successful repair by TES with transthoracic cannulation for the posthepatic segment of the IVC.

Off-pump direct hepatic veins-to-hemiazygos vein anastomosis after primary Kawashima operation: long-term result.

Direct hepatic veins-to-hemiazygos connection offers the balanced distribution of hepatic venous blood to both lungs, not requiring anticoagulation. We report a 13-year follow-up after this type of off-pump Fontan completion. Patient's hepatic veins-to-hemiazygos confluence increased with growth to allow for unobstructed flow. This unique technique can be recommended in heterotaxy patients, if atrial hepatic venous drainage and hemiazygos vein are in close proximity.

Impact of preservation of the azygos vein during surgical repair of esophageal atresia-tracheoesophageal fistula (EA-TEF): a systematic review and meta-analysis.

Esophageal atresia-tracheoesophageal fistula (EA-TEF) is one of the common congenital anomalies occurring in newborns. Over the last eight decades, various technical modifications have been proposed in the surgical repair of EA-TEF. Preservation of azygos vein is one such modification that has gained considerable attention. However, a consensus statement regarding the superiority of its preservation over its division is lacking. We aim to compare the outcomes of surgery between the two groups of newborns, i.e., those undergoing repair with and without azygos vein preservation, in terms of its complications. The authors systematically searched the databases PubMed, EMBASE, Web of Science, and Scopus through December 2020. The incidence of anastomotic complications and chest infection was compared among the two groups of newborns, i.e., those undergoing surgical repair with (group A) and without azygos vein preservation (group B). Statistical analysis was performed using a fixed-effects model, and pooled risk ratio (RR) and heterogeneity (I2) were calculated. The methodological quality of the studies was assessed using the Downs and Black scale. Six comparative studies, consisting of a total of 671 newborns, were included in the meta-analysis. As compared to group B, newborns belonging to group A showed a significantly lower incidence of pneumonitis in the postoperative period (RR 0.31; 95% CI 0.17-0.57, p = 0.0001). However, no significant difference in the incidence of anastomotic complications including anastomotic leak (RR 0.73; 95% CI 0.48-1.12, p = 0.15) and stricture (RR 0.63; 95% CI 0.36-1.09, p = 0.10) was observed between the two groups. The average Downs and Black scale scores ranged from 20 to 24. The risk of bias was low (n = 1) and moderate (n = 5) in the included studies. Kappa statistics showed a value of 0.902 (p < 0.001), highlighting an almost perfect agreement among the two observers. The present meta-analysis revealed the superiority of surgical repair of EA-TEF performed with preservation of azygos vein in terms of the incidence of postoperative chest infection. However, no significant difference in the occurrence of anastomotic leak and stricture was observed between the two groups. The level of evidence of the published comparative studies is limited. Therefore, well designed, randomized controlled trial utilizing a standardized operative approach on a larger sample-size needs to be conducted for optimal comparison between the two approaches.

Feasibility of thoracoscopic attenuation of the azygos vein as a model for portoazygos shunts: A canine cadaveric study.

OBJECTIVE: To evaluate the feasibility of thoracoscopic placement of three vascular attenuation devices by using the azygos vein as a model for portoazygos (PA) shunts and to describe the approach for thoracoscopic placement of these attenuation devices in small breed dogs. STUDY DESIGN: Randomized, prospective, cadaveric study. ANIMALS: Cadavers of 10 adult small breed dogs. METHODS: Cadavers were placed in sternal recumbency with left dorsolateral obliquity, and three thoracoscopic ports were established in the right hemithorax at the mid-10th intercostal space and dorsal third of the ninth and 11th intercostal spaces. The caudal azygos vein was thoracoscopically isolated along three adjacent segments bordered by four intercostal arteries, beginning just cranial to the first intercostal artery visualized cranial to the diaphragm. Three attenuation devices including coated cellophane, uncoated cellophane, and a 5-mm ameroid constrictor were thoracoscopically placed around one segment in each dog. Minor port access modifications were required to improve working space and triangulation in three dogs. Ability to successfully place the device, time required for placement, endoscopic clip configuration, and complications associated with placement were recorded. RESULTS: Median dog weight was 7.7 kg (range, 1.8-11). All attenuation devices were successfully placed thoracoscopically in all cadavers. No difference was detected in time required for placement between the ameroid constrictor and coated and uncoated cellophane (range, 2.3-33.8 minutes, P = .8). CONCLUSION: Ameroid constrictors and thin film bands were consistently placed via thoracoscopy around the caudal azygos vein of small breed dogs. CLINICAL SIGNIFICANCE: These results justify further investigation of thoracoscopic PA shunt attenuation in affected dogs.

Percutaneous paraspinal access to the azygos vein to create a neo-vena cava.

We present the case of a child with congenital heart disease repaired in infancy with diffuse central venous occlusions resulting in central venous insufficiency, superior vena cava (SVC) syndrome, and intracranial bleeds. He presented to the catheterization laboratory for multiple transcatheter interventions to recanalize central venous channels which were unsuccessful by conventional methods. Therefore, extravascular venous channels were created to decompress his upper body by creation of a neo-SVC and his lower body with a neo-azygos vein to the neo-SVC. The latter procedure required direct percutaneous access from a paraspinal approach in order to obtain continuity with the azygos vein. At latest follow-up the patient is clinically well and asymptomatic.

Misplacement of Tunneled Hemodialysis Catheter into Azygos Vein: Left or Right Jugular Insertion Has Similar Susceptibility.

BACKGROUND: Central venous catheter (CVC) is commonly used to provide access for hemodialysis (HD) when arteriovenous access is not available. The misplacement of CVC into azygos vein (AV) is a rare but a potential serious complication. Previous reports communicated the opinion that left-sided catheterization predisposed to AV misplacement, but these reports concentrated on peripherally inserted CVCs, placed for indications rather than HD. Unintended AV misplacement of HD catheters (HDCs) has not been well studied. We seek to investigate factors associated with inadvertent AV miscannulation during HDC placement. METHODS: We are to present a case of unintentional misplacement of a tunneled HD catheter (tHDC) into the azygos arch from right internal jugular vein (RIJV) despite real-time fluoroscopy guidance. Additionally, we have undertaken a systematic literature search in Pubmed to study the anatomical and other factors related to unintended AV misposition in HD setting. RESULTS: From 2005 to August 31, 2018, a total of 11 articles containing 16 cases of misplacement of HDCs into AV were identified. Of the 17 cases of unintentional AV misposition including ours, the majority of the misguided HDCs (94.1%, 16/17) were tHDCs and only 1 case was related to a temporary (non-tunneled) catheter. Most catheter misplacements (88.2%, 15/17) were performed without real-time radiological guidance. The reported incidence of inadvertent AV cannulation from different institutions varied between 0.6% and 3.8%. Among the 16 misplaced tHDCs, the rates of AV misposition that arose from RIJV and left internal jugular vein (LIJV) insertion are even at 50%. CONCLUSIONS: Based upon anatomical and case studies, we have found that AV may join posterior aspect of superior vena cava at different directions and levels. Hence, this might explain why AV misplacement might occur whether an HDC is inserted from the LIJV or RIJV approach. By raising the awareness of this potential complication and how we may minimize it, we hope to reduce the future complication of AV misposition.

Hepatic vein redirection to improve pulmonary arteriovenous malformations after Fontan completion in patients with absence of inferior vena cava and hemiazygos continuation.

Pulmonary arteriovenous malformation is an important complication after Fontan completion in patients with univentricular circulation. Lack of hepatic venous flow in a pulmonary artery has been identified as a cause of pulmonary arteriovenous malformation. We report our experience with a case of redirection of the hepatic vein to the hemiazygos vein using a conduit via left thoracotomy and median sternotomy for the correction of unequal distribution of hepatic venous flow in the pulmonary arteries. The pulmonary arteriovenous malformation improved, leading to increased arterial saturation levels.

Vagus nerve-preserving versus conventional laparoscopic splenectomy and azygoportal disconnection.

BACKGROUND: Conventional open and conventional laparoscopic splenectomy and azygoportal disconnection (CLSD) result in poor quality of life because of damage to the vagal nerve. We have developed vagus nerve-preserving laparoscopic splenectomy and azygoportal disconnection (VLSD). This study aimed to evaluate whether VLSD is effective and safe, and to determine whether a reduction in the incidence of postoperative complications improves postoperative quality of life compared with CLSD. METHODS: We retrospectively evaluated outcomes in 72 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent CLSD (n = 40) or VLSD (n = 32) between April 2015 and December 2016. Their demographic, intraoperative, and postoperative variables were compared. RESULTS: No patients required conversion to laparotomy in CLSD and VLSD. There was no difference in estimated intraoperative blood loss, volume of intraoperative blood transfused, time to first flatus, time to off-bed activity, and postoperative hospital stay between the two groups. VLSD was associated with a shorter operation time (P = 0.020) and less postoperative complications (P < 0.0001), including less diarrhea (P < 0.0001), epigastric fullness (P < 0.0001), and delayed gastric emptying (P < 0.0001), compared with CLSD. With VLSD, there was a significant increase in body weight and plasma albumin levels at 6 months postoperatively compared with preoperative values (all P < 0.05). The curative effect of improving esophageal/gastric variceal bleeding was similar in the groups. CONCLUSIONS: VLSD is effective and safe for reducing the incidence of postoperative complications, contributing to improving postoperative quality of life.

[Postoperative complications and survival analysis of 1 118 cases of open splenectomy and azygoportal disconnection in the treatment of portal hypertension].

Objective: To analyze the recent postoperative and long-term postoperative complications of open-splenectomy and disconnection in patients with portal hypertension. Methods: There were 1 118 cases with portal hypertension who underwent open splenectomy and azygoportal disconnection from April 2010 to September 2015 at Department of Surgery, People's Liberation Army 302 Hospital. Retrospective case investigation and telephone follow-up were conducted in October 2016. All patients had history of upper gastrointestinal bleeding before operation. Short-term complications after surgery were recorded including secondary laparotomy of postoperative abdominal hemostasis, severe infection, intake disorders, liver insufficiency, postoperative portal vein thrombosis and perioperative mortality. Long-term data including postoperative upper gastrointestinal rebleeding, postoperative survival rate and incidence of postoperative malignancy were recorded, too. GraphPad Prism 5 software for data survival analysis and charting. Results: Postoperative short-term complications in 1 118 patients included secondary laparotomy of postoperative abdominal hemostasis(1.8%, 21/1 118), severe infection(2.9%, 32/1 118), intake disorders(1.0%, 11/1 118), liver dysfunction (1.6%, 18/1 118), postoperative portal vein thrombosis(47.1%, 526/1 118)and perioperative mortality(0.5%, 5/1 118). After phone call following-up, 942 patients' long-term data were completed including 1, 3, 5 years postoperative upper gastrointestinal rebleeding rate(4.4%, 12.1%, 17.2%), 1, 3, 5-year postoperative survival rate(97.0%, 93.5%, 90.3%); the incidence of postoperative malignant tumors in 1, 3 and 5 years were 1.7%, 4.4% and 6.2%. Conclusions: Reasonable choosing of surgical indications and timing, proper performing the surgery process, effective conducting perioperative management of portal hypertension are directly related to the patient's short-term prognosis after portal hypertension. Surgical intervention can reduce the rates of patients with upper gastrointestinal rebleeding, improve survival, and do not increase the incidence of malignant tumors.

Atrial flutter ablation by femoral approach in a woman with azygos continuation of an interrupted inferior vena cava and dual chamber pacemaker.

This report describes a case of isthmus-dependent atrial flutter ablation by the femoral approach in a 54-year-old woman with a previously unknown absence of the inferior vena cava (IVC) and dual chamber pacemaker. Despite looping of the catheters, ablation and termination of atrial flutter were performed successfully without function alteration of the pacemaker leads.  This is the first report of an inferior-to-superior approach for ablation of atrial flutter in the absence of the perihepatic IVC with the presence of chronic indwelling leads in the area targeted for radiofrequency.

Anastomosis Between Thoracic Duct and Azygos Vein During Esophagectomy: A Novel Technique with 3-year Follow-up.

BACKGROUND: Ligation of thoracic duct is the standard procedure currently used to prevent postoperative chylothorax for patients undergoing esophagectomy when thoracic duct is surgically injured or invaded by tumor. However, preservation of lymphovenous circulation is particularly important for a subset of patients, including individuals with liver cirrhosis, ascites, nephrotic syndrome, sclerosing mesenteritis, or some cardiac conditions. METHODS: We have developed a new technique of restoring lymphovenous circulation for patients undergoing esophagectomy. Intrathoracic lymphovenous anastomosis was performed for an esophageal cancer patient by intravenous catheter assisted end-to-side "insertion" technique. RESULTS: The time taken for lymphovenous anastomosis was 35 min. No massive bleeding or other adverse events occurred during operation, and the patient had an uneventful postoperative course. Lipid metabolisms, assessed by pre- and postoperative plasma concentrations of cholesterol, triglycerides, high-density and low-density lipoprotein, were not affected after lymphovenous anastomosis. Lymphangiography also indicated lymphovenous anastomosis remained patent 3 years after operation. No long-term surgery-related adverse events were observed during 3-year follow-up. CONCLUSION: Lymphovenous anastomosis was successfully implemented for the patient with esophagectomy, selected patients might benefit from this novel technique.