4th Intercostal Space Research Articles

Quality of life, satisfaction and outcomes after ministernotomy versus full sternotomy isolated aortic valve replacement (QUALITY-AVR): study protocol for a randomised controlled trial

BackgroundDuring the last decade, the use of ministernotomy in cardiac surgery has increased. Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomised trials. The aim of the study is to determine if this minimally invasive approach improves quality of life, satisfaction and clinical morbimortality outcomes.Methods/designThe QUALITY-AVR trial is a single-blind, single-centre, independent, and pragmatic randomised clinical trial comparing ministernotomy (“J” shaped upper hemisternotomy toward right 4th intercostal space) to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients will be randomised in a 1:1 computational fashion. Sample size was determined for the primary end point with alpha error of 0.05 and with power of 90% in detecting differences between intervention groups of ≥ 0.10 points in change from baseline quality of life Questionnaire EuroQOL-index (EQ-5D-5 L®), measured at 1, 6 or 12 months. Secondary endpoints are: the differences in change from other baseline EQ-5D-5 L® utilities (visual analogue scale, Health Index and Severity Index), cardiac surgery specific satisfaction questionnaire (SATISCORE®), a combined safety endpoint of four major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events and acute renal failure), bleeding through drains within the first 24 h, intubation time, postoperative hospital and intensive care unit length of stay, transfusion needs during the first 72 h and 1-year survival rates. Clinical follow up is scheduled at baseline, 1, 6, and 12 months after randomization. All clinical outcomes are recorded following the Valve Academic Research Consortium 2 criteria.DiscussionThe QUALITY-AVR trial aims to test the hypothesis that ministernotomy improves quality of life, satisfaction and clinical outcomes in patients referred for isolated aortic valve replacement. Statistically significant differences favouring ministernotomy could modify the surgical “gold standard” for aortic stenosis surgery, and subsequently the need to change the control group in transcatheter aortic valve implantation trials. Recruitment started on 18 March 2016. In November 2017, 75 patients were enrolled.Trial registrationClinicalTrials.gov, NCT02726087. Registered on 13 March 2016.

Micro-incision thoracoscopic treatment of primary spontaneous pneumothorax: the "loop" technique.

Primary spontaneous pneumothorax has been defined as the disease of the 'young and healthy'. There are multiple possible therapies and in recent years, surgery has evolved towards the use of the uniportal thoracoscopic approach. The objective of our study is to describe and present an innovative approach to access to the thoracic cavity in patients with spontaneous pneumothorax. The surgery was performed using a single access of 20 mm at the level of the 8th intercostal space. For the isolation and suspension of any dystrophic area, we use a 'loop' of non-absorbable braided suture inserted through the IV intercostal space and successive wedge resection using an endoscopic 10 mm mechanical stapler. Using this access, we were able to visualize and dissect the pulmonary ligament and perform complete pleural abrasion. We had no complications. The operative time was 60 min, the chest tube was removed the 2th postoperative day and the patient was discharged the day after. The operation we propose permits the reduction of the dimension of the access to the thoracic cavity. We were able to resect blebs without problems, the recovery was excellent and no complications related to the procedure were reported.

Initial experience with a 3D printed model for preoperative simulation of the Nuss procedure for pectus excavatum

The incidence of pectus excavatum has been estimated to be between 0.1% and 0.8% though a large autopsy series reports. After publication of the Nuss procedure for pectus excavatum, it became widely accepted. However, there are still some complications, such as over-correction and recurrence. To reduce differences in the procedure due to surgeons' experience level, preoperative simulation may be useful. Thus, we performed simulated surgery using a specific patient's three-dimensional (3D) chest wall model made by a 3D printer before operation. A 13-year-old male patient with a severe deformity of the chest underwent the Nuss procedure. As in the simulation, bars were inserted into the 5th and 7th intercostal spaces (ICS), leading to improvement of the chest wall. This simulation can increase surgeons' confidence to improve the deformity by determination of the number and insertion sites of bars.

Single-Port Thoracoscopic Pericardial Window under Local Anesthesia

There are numerous surgical approaches for the treatment of pericardial effusions but no clear consensus of best management. We present a 44-year-old woman with metastatic breast cancer presenting with a new 2-cm pericardial effusion on ultrasound. In light of the patient's palliative condition and the urgent need for chemotherapy, careful consideration was made for her surgical drainage of the pericardial effusion. Because of the patient's medical comorbidities, a general anesthetic was deemed not to be in the patient's best interest. Furthermore, the invasive subxiphoid or thoracotomy approach for a pericardial window would have risked delaying her much needed chemotherapy. A single-port thoracoscopic pericardial window was performed under light sedation, ventilating spontaneously on supplementary oxygen through nasal cannula only. The patient was positioned in a supine position, and a single 8-mm port was inserted into the left hemithorax at the 5th intercostal space, midaxillary line under local anesthetic, and a pericardial window made. This minimally invasive approach, without the need for intubation or ventilation, allowed for rapid relief of symptoms and discharge for the patient to begin her chemotherapy in a timely manner. By undergoing the procedure awake and through a single port, the patient was discharged after a short inpatient stay. This novel approach can be advocated for patients where a general anesthetic or invasive surgical procedure is not suitable in the treatment of their pericardial effusion.

Extubation success can be better predicted by diaphragmatic excursion using ultrasound compared to rapid shallow breathing index

INTRODUCTION Mechanical ventilation is one of the cornerstones of ICU care and can change the outcome of critically ill patients.[1] Old age, prolonged ICU stay as well as critical illness myopathy and neuropathy due to the aforementioned factors compounded by the use of steroids or muscle relaxants can contribute to chances of extubation failure.[2] A rapid shallow breathing index (RSBI) of >105 is indicative of a high respiratory frequency and shallow breaths, or reduced tidal volumes, and maybe a predictor of unsuccessful extubation.[3] In a previous study, a change in diaphragmatic thickness of >30% had a positive predictive value of 91% for predicting successful extubation.[345] Our aim was to do a pilot study to compare diaphragmatic excursion by use of a point-of-care ultrasound by an ICU clinician who is proficient in the use of ultrasound to RSBI in predicting extubation success. METHODS Our study was a prospective, observational, comparative cohort study. Institutional Review Board approval was obtained for this study (for the use and recording of the diaphragmatic ultrasound) and informed consent was obtained from the family members and the patient post-extubation. A small predetermined sample size of 20 was used as a pilot to find a positive trend for use in a larger study thereafter. All patients received spontaneous breathing trials before extubation and were assessed for extubation by the ICU team prior to the study. An RSBI of >105 was predictive of poor chances of extubation success, and these patients were automatically excluded as they were not chosen for extubation by the ICU team at that point. Patients who had spinal, neurological, or diaphragmatic injury were excluded as this could hamper their diaphragmatic excursions. All patients could follow breathing commands on nil or minimal sedation in a semi-recumbent position. Extubation success was deemed to be as a lack of need for invasive or noninvasive ventilator support at 48 h. The zone of diaphragmatic apposition to the rib cage at the anterior axillary line in the right 8th intercostal space was used for identifying the diaphragm in all cases. It is technically difficult to visualise the left side due to the presence of the spleen. The patient was encouraged to take three or four vital capacity breaths. Since we were not timing the excursion to the breathing cycle in order for the clinician to complete the study successfully and easily, an average excursion of >1.5 cm at any point in the vital capacity breath was chosen as indicative of predictive of successful extubation. RESULTS Twenty observations on 20 patients were made. The ICU clinician practiced on three patients prior to the start of the study to achieve the learning curve of this strategy of identifying the diaphragm. The average age of the patients was 52 years and ranged from 21 to 89 years. 14 males and 6 female patients were recruited. The average length of stay was 5.5 days ranging from 1 to 14 days. The average RSBI was 40 (SD 17.0170), whilst the average excursion of the diaphragm was 1.98 cm (SD 0.47958). Univariate logistic regressions were performed to examine the effect of diaphragmatic excursion and RSBI on the likelihood of extubation failure. The odds of extubation success increased by 249.8 times (95% CI = {1.33, 46801}, P value = 0.039), and for an increase by 1 in RSBI, the odds of extubation failure increased by 1.008 times (95% CI = [0.94, 1.08], P value = 0.82). As shown in Figures 1 and 2, the modelled predictions of diaphragmatic excursion and RSBI are also compared using the area under the curve (AUC) from the ROC curves. A larger AUC indicates a higher predictive power of model. The diaphragmatic excursion model yields a larger AUC 0.92 (95% CI = [0.77, 1.0]) than the RSBI model with AUC 0.58 (95% CI = [0.27, 0.89]).Figure 1: ROC curve for diaphragmatic excursionFigure 2: ROC curve for RSBIDISCUSSION Evaluating diaphragmatic thickness and change with respiration is operator dependent and can lead to inaccurate results. Such studies have been done by experts in the field of ICU ultrasonography and require a fair deal of expertise. The odds ratio ranges for confidence intervals are wide probably due to the small sample size. From the results of this small pilot study, it seems that diaphragmatic excursion as evaluated by a point-of-care ultrasound is probably better in predicting extubation success than RSBI; however, bigger sample sizes are needed for verifying this result. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement We acknowledge the contributions of Ms. Jiexun Wang and Mr Robin Choo for helping us with the statistics.

Periareolar Access for Minimally Invasive Cardiac Surgery: The Brazilian Technique.

The periareolar access has been the preferred technique used at our institution for minimally invasive cardiac surgery since 2006. The surgical approach consists of video-assisted minithoracotomy in the 4th right intercostal space, through a periareolar incision. Initially, the technique was restricted to minimally invasive mitral valve surgeries but, due to its feasibility and safety, was soon incorporated as an ideal access for other cardiac pathologies such as tricuspid valve disease, atrial septal defect, atrial fibrillation, and pacemaker leads endocarditis. The technique was performed in 214 patients, and it is associated with excellent aesthetic and functional results, with low morbimortality and no reoperations at long-term follow-up. Here, we describe and support the use of periareolar access as a routine surgical technique for correction of several cardiac pathologies, especially in women.

Development of a weight-estimation model to use in pregnant criollo-type mares

ABSTRACT: The aims of this study were: 1) to compare the tape weight and associated weight-estimation formula to evaluate weight gain in pregnant mares, and 2) to develop a mathematical model to estimate the weight of pregnant mares using body measurements. Thirty-four criollo-type mares were evaluated every two weeks during the middle and late pregnancy. The mares were weighed on a livestock scale, and we estimated body weight using tape weights and an associated body-weight estimation formula. Also, heart-girth circumference (heartgirth) and abdominal circumference were measured; the latter at the 12th intercostal space (12th ICS) and 18th rib (18th Rib), to use in a mathematical model to estimate the weight of pregnant mares. Observations were divided into three periods of pregnancy: 5th to 7 h month, 7th to 9 h month, and 9th to 11th month. Mares in late pregnancy showed an increase in actual weight and an increase in 12th ICS and 18th Rib measurements. Tape weight and body-weight estimation formula underestimated the weight of pregnant mares. However, the regression model using heart-girth circumference, 12th ICS, and 18th Rib measurements showed high correlation (r2 = 0.87, P<0.001) with actual weight. Finally, the alternative methods usually used in horses are not accurate to estimate body weight in pregnant mares. In conclusion, the regression model Y=-540.143 + (heartgirth x 3.068) + (12th ICS x 1.278) + (18th Rib x 0.944) can be used to estimate body weight in pregnant mares from the 5th to 11th months of pregnancy.

Large Aorto-Pulmonary Window (APW) associated with severe pulmonary hypertension: A case report

Background: APW is a rare congenital cardiac abnormality, accounting for 0.2% to 0.6% of patients. Hence the reported surgical experience is minimal. It is a communication b/w pulmonary artery (PA) and the ascending aorta (Ao), in the presence of two separate semi lunar valves. Heart failure and irreversible pulmonary hypertension are the fearsome outcomes of untreated APW. Therefore, surgical closure is the first-line curative choice. We present a case of young boy who presented late in age (his second decade of life) with severe signs and symptoms. Case Presentation: A 12-year-old male patient from Baluchistan (balochi) presented with complaints of high grade fever for one week, palpitations since 12 days, along with past history of shortness of breath. On examination patient was anemic, cyanosed with raised JVP. On precordial examination apex beat was localized at the 6th intercostal space shifted to mid-axillary line. S1 was normal but S2 was loud with prominent pulmonary component. Grade IV/VI continuous murmur was heard in the left upper sterna border. Chest X-ray showed cardiomegaly with prominent pulmonary artery (PA) and bilateral lung congestion. Echocardiography showed enlarged and hypertrophied right ventricle associated with dilated PA and a large APW was seen with severe pulmonary artery pressure (PAP) of 102 mmHg. Diagnosis of APW was confirmed on cardiac catheterization. Furthermore, cardiac CT was performed which showed type I APW with severe PH and large patent PDA (patent ductus arteriosus). Patient then underwent repair of APW associated with reactive pulmonary hypertension that had a complete repair utilizing a trans-aortic approach. PDA was also ligated during the same procedure. Patient symptoms remarkably improved with a reduction PAP (40mmHg) after surgery and at 6 weeks follow-up. Follow-up echocardiography showed complete closure of the APW, and pharmacological therapy was no longer required in the patient. Conclusion: APW should be suspected in any child, who comes with repeated chest infections and signs of congestive heart failure. It should be surgically corrected early, in order to prevent the development of obstructive pulmonary vascular disease. There is conflict of interest.

Posterior uniportal video-assisted thoracoscopic surgery for anatomical lung resections.

The acceptance of uniportal video-assisted thoracoscopic surgery (uVATS) for anatomical lung resections has been growing in recent years. This study presents the first case-series in the literature with posterior uVATS (puVATS) technique for specific anatomical lung resections. The first 20 consecutive patients who underwent an anatomical lung resection by a single surgeon, by means of puVATS technique were evaluated in terms of pre-, peri- and post-operative results. A single incision of 3.5-4.5 cm was made posteriorly in the 6th intercostal space at the so-called 'triangle of auscultation' to perform a resection of either a posterior segment of an upper lobe or a superior segment of a lower lobe for both lungs. There were 5 posterior segmentectomies and 3 apical segmentectomies of the right upper lobe and 6 apical segmentectomies of the left lower lobe. Moreover, there were 6 lobectomies, all except for one as an extension of initially planned "posterior" segmentectomy. There were no intraoperative complications. Median tumor size (IQR) was 1.65 cm (1.1-2.57 cm), while median incision size (IQR) was 3.5 cm (3.5-3.87 cm). Median operative time (IQR) was 160 minutes (142-178 minutes). Median number of removed lymph nodes (IQR) was 19 [15-20]. Four patients had postoperative complications: three had bronchitis and one developed heart failure, all of which resolved before patients were discharged. Median length of hospital stay (IQR) was 6 days (5-8 days). puVATS approach for posterior lung segment resections, even for lobectomy if needed, seems to be feasible and safe. Exposure of the bronchovascular structures of the 'posterior segments' is better, and local and mediastinal lymphadenectomy seem to be easier with access directly in front of the incision and the lung, rather than behind it.

Значение торакоскопии при открытых ранениях грудной клетки для выбора лечебной тактики

Results of 163 thoracoscopic examinations for thoracic trauma are presented. In all cases, the the cause of the injury was stabbing. Among the patients, there were 147 men (90.2 %) and 17 women (9.8 %). Thoracoscopy was performed under local anesthesia or endotracheal anesthesia (predominantly), in a semi-lateral position on the healthy side with a reliable fixation of the patient, which is necessary, since it sometimes there is need to change the position of the table. The first thoracoport was usually introduced into the 5th intercostal space. After the revision of the pleural cavity, according to the indications, places of additional punctures and the introduction of appropriate instruments were determined. For evacuation of blood from the pleural cavity an electric pump was used. For hemostasis, electrocoagulation was commonly applied, and in a number of cases we used the haemostatic sponge. To stop bleeding from the lung tissue, as well as for aerostasis, the Roeder loop was used. After thoracoscopy, the question of further tactics was resolved. With ineffective thoracoscopy, thoracotomy was required. In case of successful thoracoscopy, the operation was finished with draining the pleural cavity through the most adequately located punctures. Thoracoscopy is an effective method of determining further tactics in this pathology. With a trauma in the danger zone, 41 of 62 patients managed to avoid conversion. In many cases thoracoscopy allows to perform hemostasis, aerostasis and other curative measures. It also can reduce the amount of thoracotomy by 2-2.5 times

Uniportal video-assisted thoracic surgery for esophageal cancer.

Classical video-assisted thoracic surgery (VATS) approach to esophageal cancer uses four incisions. The rationale is to facilitate movement of the instruments and the esophagus and also suturing during placement of a purse-string suture for an intrathoracic anastomosis. Uniportal VATS (U-VATS) is challenge for surgeons, as you have to do an esophageal mobilization and anastomosis from a single 3-5 cm incision. The incision is placed either at the 5th or 6th intercostal space close to the posterior axillary line. Esophagus is mobilized en bloc with the subcarinal and periesophageal lymph nodes. The crucial parts are inclusion of subcarinal lymph node in the specimen, mobilization of the specimen from the left main bronchus and esophagogastric anastomosis. Esophagus is encircled with a thick penrose drain and retracted anterior and posteriorly during this dissection. Once the esophagus is completely mobilized, if an intrathoracic anastomosis is to be performed, gastric conduit is pulled inside the chest in correct orientation. A linear completely stapled side to side anastomosis is performed. A thick tissue endoscopic stapler is used for posterior and anterior wall. A single chest drain is placed and incision is closed. There are several intrathoracic anastomotic techniques. All of these techniques can be applied through a uniportal approach. Side to side completely stapled anastomosis is safe, fast and easy to perform. There is a single report on esophagectomy comparing uniportal and multiportal VATS approaches in esophageal cancer which showed comparable results in terms of duration of surgery, amount of bleeding, lymph node yield and leak rates. U-VATS for esophageal cancer is emerging as a new approach and the technique is feasible and certainly future studies will show if it is reproducible and provides a clinical advantage for the patient.

Right dorsal colon ultrasonography in normal adult ponies and miniature horses.

The aim of this study was to determine the normal location, wall thickness and motility of the right dorsal colon in adult ponies and miniature horses. The abdominal ultrasonography examination was performed in a study group consisting of 23 ponies and miniature horses and in a control group comprising ten Thoroughbred horses. The procedure was performed in unsedated standing animals. The location and the thickness of the right dorsal colonic wall was examined on the right side of the abdomen between the 10th and the 14th intercostal space. The contractility was recorded in the 12th intercostal space. A comparative analysis between the study group and control group was carried out using the Student’s t-test. Pearson’s linear correlation coefficient was used to calculate the correlation between the thickness of the colonic wall as well as the number of peristaltic movements and age, wither height and body mass of the animals. The right dorsal colon was identified in all the horses in the 12th intercostal space. In all the intercostal spaces the mean ± standard deviation (SD) wall thickness of the right dorsal colon was 0.27 ± 0.03 cm in the horses from the study group and 0.37 ± 0.03 cm in the control horses. The mean number of peristaltic contractions was 4.05 ± 1.07 per minute in the animals from the study group and 1.7 ± 0.46 contractions per minute in the control group. The values of the ultrasonographic wall thickness and peristaltic motility in small breed horses in the present study were different from the values obtained for large breed horses. The study also found that the right dorsal colon in small breed horses is physiologically located in the 12th intercostal space. This suggests that different reference values should be used in small horse breeds when performing an ultrasound examination.

Comparative studies of different types of osteosynthesis on the human corpse preparation in bilateral antero-lateral flail chest

IntroductionBilateral flail chest injuries are challenging in treatment and comparatively often require an operative stabilization of the anterior chest wall to re-establish normal physiological conditions of the chest wall in shape and statics. Various procedures have been described which are technically sophisticated for the surgeon. Consequently there is an increasing interest in potentials of operative care and their effectiveness on the anterolateral chest wall. Materials and methods12 Human cadavers were prepared and the natural Sternum Position (NP) was marked. A digital probe was fixed to the sternum at the height of the 4th intercostal space in order to measure and compare the stability of the thorax. Readings were taken of the sternal displacement at 1–5cm sagittal distance from NP in starting conditions and from every combination of materials. Serial osteotomies were performed on 2 locations on ribs 2–8 to induce bilateral flail chest.Afterwards the stabilization was achieved with different implants:–Transsternal metalstrut.–Several combinations of locking plate fixation. ResultsThe osteotomies lead to a subsidence of the sternum occurred to almost 75 mm from NP which corresponds to a maximal unstable situation. The unstable chest wall showed substantially more stabilization through the use of locking plates. Our materialcombinations showed a stability of up to 60% of normal. The more ribs were treated osteosynthetically, the higher the stability of the chest wall. Discussion and conclusionsLocking plate fixation offers anatomically realignment of the ribs whereas metal strut support only lifts up the chest wall, but could not provide realignment of the dislocated ribs.

Portal Vein Dopplerflowmetry in healthy sheep according to age

ABSTRACT: Pulsed Doppler ultrasound was used to evaluate portal blood flow, portal velocity and portal congestion index in 24 healthy sheep divided into groups (lambs, yearlings and ewes), according to age. Measurements were performed at the 11th right intercostal space using ideal insonation angle and uniform insonation method. Mean values obtained in each group were compared with one-way ANOVA, followed by Tukey post-hoc test. Portal velocity and portal blood flow were statistically similar between the groups (P>0.05). Mean portal velocity were 17.75; 17.13 and 16.75; while mean portal blood flow were 26.65; 31.04 and 24.32 for lambs, yearlings and ewes, respectively. Portal congestion index was statistically distinct between the groups and values for lambs, yearlings and ewes were 0.009; 0.058 and 0.09, respectively (P<0.01). Statistical differences were observed in portal vein diameter, portal vein area and portal congestion index between the groups, presumably due to influence of weight and not to age.

Inverting the laparoscopic cholecystectomy: a case of acute biliary pancreatitis in situs inversus

A 57-year-old female presented in Outpatient Department with complaints of left upper abdominal pain for last 5 days. She had left hypochondrial and epigastric tenderness with apex beat palpable in right 5th intercostal space. Diagnostic work-up revealed acute biliary pancreatitis with situs inversus totalis. Abdominal sonogram showed left sided distended gallbladder with multiple stones. Laparoscopic cholecystectomy was done after initial stabilization of the patient. Patient’s recovery was uneventful in the postoperative period.

370 The Relationship Between Adult Body Mass Index and Anticipated Failure Rate of Needle Decompression Using a 5 cm Needle for Tension Pneumothorax

Tension pneumothorax is traumatic injury that can lead to rapid circulatory collapse and death. Emergent needle thoracostomy can quickly treat tension pneumothorax, but the best anatomic location and catheter length necessary to perform the intervention has been questioned in the recent years given the increasing rates of obesity in our population. We conducted a retrospective review of a convenience sample of all trauma patients admitted to our level 1 trauma center in Minneapolis, MN who underwent chest computed tomography (CT) during their admission between 2011 and 2012. Using these CT radiographs, chest wall thickness was measured bilaterally at the 2nd intercostal space (ICS) at the midclavicular line, and at the 4th and 5th intercostal spaces at the anterior axillary line. Baseline demographic data including age, sex, BMI, ISS and associated chest wall trauma were collected from medical chart review. Needle thoracostomy failure was defined as chest wall thickness (CWT) of > 5cm, based on the length of commonly used needle decompression needles. 141 patients who met all inclusion criteria were identified. There were no significant differences in mean CWT at any of the anatomic sites. CWT was similar between males and females. BMI > 30 was associated with an adjusted odds ratio of 13.8 (confidence interval 4.8-39.8) for failure with a standard 5cm catheter needle decompression. In the increasingly obese general population, needle thoracostomy with a standard 5cm needle may be more prone to failure. Adult BMI > 30 is a significant risk factor for anticipated failure of needle tube decompression. Alternative anatomic sites for needle decompression did not appear to increase the anticipated success of the intervention.

B-lines with Lung Ultrasound: The Optimal Scan Technique at Rest and During Stress

Various lung ultrasound (LUS) scanning modalities have been proposed for the detection of B-lines, also referred to as ultrasound lung comets, which are an important indication of extravascular lung water at rest and after exercise stress echo (ESE). The aim of our study was to assess the lung water spatial distribution (comet map) at rest and after ESE. We performed LUS at rest and immediately after semi-supine ESE in 135 patients (45 women, 90 men; age 62 ± 12 y, resting left ventricular ejection fraction = 41 ± 13%) with known or suspected heart failure or coronary artery disease. B-lines were measured by scanning 28 intercostal spaces (ISs) on the antero-lateral chest, 2nd–5th IS, along with the midaxillary (MA), anterior axillary (AA), mid-clavicular (MC) and parasternal (PS) lines. Complete 28-region, 16-region (3rd and 4th IS), 8-region (3rd IS), 4-region (3rd IS, only AA and MA) and 1-region (left 3rd IS, MA) scans were analyzed. In each space, the B-lines were counted from 0 = black lung to 10 = white lung. Interpretable images were obtained in all spaces (feasibility = 100 %). B-lines (>0 in at least 1 space) were present at ESE in 93 patients (69%) and absent in 42. More B-lines were found in the 3rd IS and along AA and MA lines. The B-line cumulative distribution was symmetric at rest (right/left = 1.10) and asymmetric with left lung predominance during stress (right/left = 0.67). The correlation of per-patient B-line number between 28-S and 16-S (R2 = 0.9478), 8-S (R2 = 0.9478) and 4-S scan (R2 = 0.9146) was excellent, but only good with 1-S (R2 = 0.8101). The average imaging and online analysis time were 5 s per space. In conclusion, during ESE, the comet map of lung water accumulation follows a predictable spatial pattern with wet spots preferentially aligned with the third IS and along the AA and MA lines. The time-saving 4-region scan is especially convenient during stress, simply dismissing dry regions and focusing on wet regions alone.

Supracarinal dissection of the oesophagus and lymphadenectomy by MIE.

Since 1995, video-assisted thoracoscopic oesophagectomy (VATS), according the same surgical principles as the Japanese open surgery, has been completed in 700 patients with oesophageal cancer. Our indication for VATS is (I) no extensive pleural adhesion; (II) no contiguous tumor spread; (III) pulmonary function capable of sustaining single-lung ventilation, and (IV) non radiated patients. We use 4 ports around a 5 cm mini-thoracotomy on 5th intercostal space. We laid emphasis on utilizing magnifying effect of video (5 to 20 magnifications), obtained by positioning the camera at close vicinity to the dissection. Magnified view facilitates recognizing the fine layer structure of the mediastinum. The dissection should be performed following this layer structure just like open the page of a book. Tearing the layer makes the dissection irrational and cause unnecessary bleeding and invasiveness. The microanatomies we recognize during upper mediastinal dissection are (I) the most outer layer below the mediastinal pleura are branches from the vagus nerve and thoracic sympathetic trunk; (II) there is no vessel flow in the nerves or out, in the field of dissection; (III) the ideal layer of dissection along the nerve is exposing the epineurium; (IV) the strongest fixing structures in the mediastinum are the vagal nerves and nerves form thoracic sympathetic trunk; (V) the stump of thoracic duct shows particular appearance because of the intramural smooth muscle; (VI) the lymphonodes in the mediastinum are fixed strongly with nerves and gently with vessels; (VII) the aorta is covered with fine fibrous membrane consisting of branches form thoracic sympathetic trunk, etc. Magnified view shows the microstructure of the lymph node such as the afferent lymphatics penetrating the capsule and the hilum structure consisting the efferent lymphatics, artery, vein and nerve. The direction of the hilum of nodes is defined in each region. Therefore, understanding the hilum direction facilitates rational dissection. The hospital mortality was four patients (0.6%). The rate of regional control was 95%. The 5-year survival rates of the patients with pStage 0, 1, 2, 3, 4 were 92%, 88%, 69%, 52% and 24%, respectively, which were favorably compared with open surgery.

Case report: Feasibility of thoracoscopic epicardial pacing in two dogs: Clinical and surgical features, and outcome

Summary This article reports the feasibility of thoracoscopic epicardial pacing in two dogs with permanent bradyarrhythmia requiring pacemaker therapy. Both dogs presented with third degree atrioventricular block. Pre-operative examinations revealed no contraindication to pacemaker therapy. A three-port subxiphoid thoracoscopic approach was used. Pericardectomy was performed to access the epicardium. A sutureless unipolar epicardial pacing lead was placed. The lead was introduced through a 15 mm cannula positioned in the 6th left intercostal space and implanted within the epicardium. The pacemaker generator pocket was created between latissimus dorsi and intercostal muscles. Lead implantation was achieved after one attempt for dog 1, and three for dog 2. Surgical times were respectively 26 and 44 minutes. Pacemaker therapy was effective after surgery for both dogs. Complications included Twiddler's syndrome in the first dog and a seroma in the second. The above technique was compared to the transdiaphragmatic approach in a limited cadaveric study on two dogs to establish the precise location of the epicardial leads for each technique. It demonstrated that thoracoscopic approach paced the right ventricle, while transdiaphragmatic technique paced the left ventricle.

A reappraisal of pediatric thoracic surface anatomy.

Accurate knowledge of surface anatomy is fundamental to safe clinical practice. A paucity of evidence in the literature regarding thoracic surface anatomy in children was identified. The associations between surface landmarks and internal structures were meticulously analyzed by reviewing high quality computed tomography (CT) images of 77 children aged from four days to 12 years. The results confirmed that the sternal angle is an accurate surface landmark for the azygos-superior vena cava junction in a plane through to the level of upper T4 from birth to age four, and to lower T4 in older children. The concavity of the aortic arch was slightly below this plane and the tracheal and pulmonary artery bifurcations were even lower. The cardiac apex was typically at the 5th intercostal space (ICS) from birth to age four, at the 4th ICS and 5th rib in 4-12 year olds, and close to the midclavicular line at all ages. The lower border of the diaphragm was at the level of the 6th or 7th rib at the midclavicular line, the 7th ICS and 8th rib at the midaxillary line, and the 11th thoracic vertebra posteriorly. The domes of the diaphragm were generally flatter and lower in children, typically only one rib level higher than its anterior level at the midclavicular line. Diaphragm apertures were most commonly around the level of T9, T10, and T11 for the IVC, esophagus and aorta, respectively. This is the first study to provide an evidence-base for thoracic surface anatomy in children. Clin. Anat. 30:788-794, 2017. © 2017Wiley Periodicals, Inc.