Anterior Axillary Research Articles

Ultrasonographic reliability and repeatability of simultaneous bilateral assessment of diaphragm muscle thickness during normal breathing.

The diaphragm is considered the main muscle involved in breathing and also linked to trunk stabilization functions. Up to date, rehabilitative ultrasound imaging (RUSI) has been the most used technique to evaluate unilaterally the transcostal diaphragm thickness. Nevertheless, the inspiratory activity of both hemi-diaphragms is bilaterally performed at the same time, and its simultaneous evaluation with a thoracic orthosis could improve its assessment as well as its re-education with visual biofeedback of both hemi-diaphragms at the same time. The purpose was to evaluate the reliability and repeatability of simultaneous thickness measurements of both hemi-diaphragms bilaterally during normal breathing using a thoracic orthosis that allowed bilateral fixation of both right and left ultrasound probes. The study was conducted in 46 healthy subjects, whose diaphragm thickness was measured bilaterally and simultaneously in the anterior axillary line during relaxed breathing with a designed thoracic orthosis and 2 ultrasound tools. Intra-examiner (same examiner), inter-examiner (2 examiners), intra-session (1 hour) and inter-session (1 week) reliability and repeatability between each pair of measurements of diaphragm muscle thickness were analyzed during normal breathing. Reliability and repeatability for intra-session evaluations using the thoracic orthosis were excellent to evaluate simultaneous thickness of both hemi-diaphragms by bilateral probes fixation (intraclass correlation coefficient =0.919-0.997; standard error of measurement =0.002-0.007 cm; minimum detectable change =0.006-0.020 cm), without systematic errors (P>0.05) between each pair of measurements. Nevertheless, inter-session evaluations varied from good to excellent using the bilateral probes fixation (intraclass correlation coefficient =0.614-0.984; standard error of measurement =0.006-0.028 cm; minimum detectable change =0.017-0.079 cm), although some systematic errors were presented (P<0.05). Good to excellent reliability and repeatability was shown for simultaneous thickness measurements of both hemi-diaphragms bilaterally during normal breathing. Despite systematic errors were presented for some inter-examiner assessments, the use of the thoracic orthosis that allowed bilateral fixation of ultrasound probes could be recommended for simultaneous hemi-diaphragms breathing re-education by visual biofeedback.

Right gasless transaxillary endoscopic total thyroidectomy (RGTETT) with video: our experience with the posterior approach: Lei's seven-sinking method.

Our video demonstrates a modified gasless transaxillary endoscopic thyroid surgery with the posterior approach for bilateral low-risk thyroid cancer. In this paper, we provided a detailed introduction to the right gasless transaxillary endoscopic total thyroidectomy surgical procedure for bilateral low-risk thyroid cancer, and briefly summarized the Lei's seven-sinking method: sinking the clavicular head of the sternocleidomastoid muscle (CHSCM); sinking the cervical vascular sheath; sinking the right wall of the esophagus; sinking the right recurrent laryngeal nerve (RLN); sinking the trachea; sinking the left RLN and sinking the thyroid. A 5-cm incision was made starting from the anterior axillary line along the natural fold at the axilla. A trocar was placed in the axillary incision approximately 3-5 cm away from the side of the breast and slightly below the anterior axillary line. Using blunt dissection and electrocautery, a working space was created by elevating a subcutaneous flap above the pectoralis major muscle. The thyroid bed was accessed through the two heads of the SCM, and then the thyroid was separated from the strap muscles. Thyroidectomy and central lymph node dissection were fully endoscopically performed with the posterior approach using conventional endoscopic instruments. Through the posterior approach and the operation steps of the seven-sinking method, total thyroidectomy and bilateral central lymph node dissection can be achieved relatively easily.

Malignant Small Round Cell Tumor: A Rare Aggressive Malignancy-Case Report

Background: Malignant Small round Cell Tumor (MSRCT) is very rare group of tumors. Malignant cells have similar histologic appearance making it difficult to distinguish one from another, and poses a diagnostic challenge with needs for a multimodal approach. Immunohistochemistry and immunophenotyping by flow cytometry, reverse transcriptase polymer chain reaction (RT-PCR) and fluorescence in situ hybridization are needed to confirm. The appropriate and best treatment in early stages of MSRCT is early surgical excision with chemoradiotherapy based on patient specification. Inspite of all these, tumors have poor prognosis and chance of recurrence are high. Method: Case study of a 27-year-old male who presented with a non-productive cough for 4 weeks, with feverish feeling with weight loss and shortness of breath and a new onset precordial chest pain non radiating and worse on exertion. On examination his vitals were: BP 121/91 mm of hg, pulse rate 114bpm, temperature 36.3 degrees Celsius, respiratory rate 24/per min, SPO2 96%.On examination, Elevated Jugular Venous Pressure, hyperactive precordium, displaced apex beat to 6th intercostal space anterior axillary line, muffled heart sounds and bilateral lower limb edema. Respiratory exam was unremarkable. Sputum gene expert was negative for mycobacterium tuberculosis and covid 19 rapid test was negative. Chest X Ray showed cardiomegaly and a transthoracic echocardiography revealed moderate-large pericardial effusion, with mild collapse of right atrium in diastole. Pericardiocentesis done showed hemorrhagic effusion with lymphocytes cell component, patient was initiated on treatment for TB pericarditis empirically. Three months later a chest CT scan done revealed extensive mediastinal/pericardial mass with lung nodules. An ultrasound guided mediastinal/Pericardial biopsy was done, revealed a poorly differentiated small round cell carcinoma. Results: Patient expired 14 weeks from the initial onset of symptoms while awaiting immunohistochemistry studies for specific diagnosis of the tumor and oncology review. Discussion: This demonstrates the complexity of establishing differential diagnosis of MSRCT in a resource limited setting with subsequent delay in treatment initiation, heralds poor prognosis. This also confirms difficulties in establishing differential diagnosis in poorly differentiated tumor.

Sub-axillary cosmetic incision versus single-incision thoracoscopic surgery for primary spontaneous pneumothorax

BackgroundIn recent years, single-incision thoracoscopic surgery (SITS) has been increasingly applied as an optimal treatment option for primary spontaneous pneumothorax (PSP). However, most SITS techniques are used in the fourth to sixth intercostal space between the anterior axillary and mid axillary lines. To find out more concealed incisions, this study performed PSP surgery via the sub-axillary cosmetic incision (SACI) technique.MethodsA total of 128 PSP patients were subjected to video-assisted thoracoscopic surgery (VATS) between January 2017 and January 2019 at our institution. These patients were evaluated and assigned into SACI (n = 21) and SITS (n = 57) groups. Propensity score matching (PSM) was performed based on patients’ backgrounds, and the enrolled cohort was divided into 21 pairs. The incision satisfaction was assessed at 2 weeks and 6 months post-surgery.ResultsThe 21 pairs with matching baseline characteristics in the two groups did not exhibit significant differences in their backgrounds and surgical results. However, compared with the SITS group, the operation time was longer in the SACI group (p = 0.013). There were no post-operative complications in both groups. At 2 weeks and 6 months, incision satisfaction scores in the SACI group were significantly lower than those in the SITS group (p = 0.022 and p = 0.039, respectively). There were no recurrences of ipsilateral pneumothorax in both groups.ConclusionsSACI is a safe and feasible surgical method for PSP treatment. In addition, incision concealment can be used for patients with incision needs.

#4865 OBSERVATIONAL PILOT STUDY TO EVALUATE THE RELATIONSHIP BETWEEN LUNG ULTRASOUND AND BIOIMPEDANCE IN HEMODIALYSIS

Abstract Background and Aims There is a clear relationship between volume overload and morbidity and mortality in hemodialysis patients, which makes it essential to accurately adjust the normohydrated weight. For this, bioimpedance has become an indispensable tool in dialysis units. In recent years there has been a rapid development of lung ultrasound for the evaluation of pulmonary congestion through the quantification of B lines. Several studies have shown a correlation between the number of B lines and the volume overload estimated by bioimpedance in patients on dialysis. However, all these studies perform a 28-zone lung ultrasound protocol, which may be a limitation in clinical practice. Several studies have recently been published showing a correlation between 28-zone lung ultrasound protocol and simplified 4, 6, and 8-zone ultrasound protocols, which have been widely studied in patients treated in intensive care or emergency units. We set out to evaluate the relationship between bioimpedance and simplified 8-zone lung ultrasound protocol in hemodialysis patients. Method Pilot cross-sectional observation study that included 29 patients on hemodialysis at Infanta Sofía University Hospital during March 2022. Bioimpedance predialysis and postdialysis, 8-zone lung ultrasound protocol (delimited by the parasternal, anterior axillary, posterior axillary, and 4th intercostal space) and inferior vena cava ultrasound. Predialysis proBNP and Ca-125 were measured. Results There is a significant reduction in overhydration estimated by bioimpedance and in the number of B lines after the hemodialysis session (p&amp;lt;0.05). No correlation has been established between the two parameters, neither pre-dialysis nor post-dialysis. Nor with the pre-dialysis levels of proBNP or Ca125. There is a correlation of r = 0.45 (p&amp;lt;0.05) in the subgroup of patients from the afternoon shift (n = 9) between the number of B lines and extracellular water. Conclusion Lung ultrasound allows the evaluation of the degree of lung congestion, and therefore of extracellular water, becoming a useful tool for adjusting the dry weight of hemodialysis patients. In our study we found no association between the number of B lines in the simplified 8-zone lung ultrasound protocol. It is possible that this type of lung ultrasound is not sensitive enough in outpatients on hemodialysis, but it is sensitive enough in critically ill patients in whom lung overload is greater. Further studies with a larger number of patients are needed for evaluation.

Reliable Location of Upper Extremity Lymphatic Channels for Use in Immediate Lymphatic Reconstruction.

Breast cancer-related lymphedema (BCRL) is a limiting sequelae of breast cancer treatment that may negatively impact 30% to 50% of high-risk breast cancer survivors. Risk factors for development of BCRL include axillary lymph node dissection (ALND), and recently, axillary reverse lymphatic mapping and immediate lymphovenous reconstruction (ILR) at time of ALND have been implemented to prevent BCRL. Reliable anatomy of neighboring venules has been commented on in the literature; however, little information exists about anatomical location of local lymphatic channels amenable for bypass. After institutional review board approval, patients who underwent ALND with axillary reverse lymphatic mapping and ILR at a tertiary cancer center from November 2021 to August 2022 were applicable for this study. The location and number of lymphatic channels used for ILR were identified and measured intraoperatively with the arm abducted to 90 degrees and soft tissue under no tension. Four measurements were taken to localize each lymphatic and were based on relationship with reliable anatomic landmarks including 4th rib, anterior axillary line, and lower border of the pectoralis major muscle. Demographics, oncologic treatments, intraoperative factors, and outcomes were prospectively maintained. Twenty-seven patients met inclusion for this study by August 2022 with a total of 86 lymphatic channels identified. Patients were on average 50 ± 12 years old with a body mass index of 30 ± 6 and had an average of 1 vein and 3 identifiable lymphatic channels amenable to bypass. Seventy percent of lymphatic channels were found in a cluster of 2 or more channels. The average horizontal location was 4.5 ± 1.4 cm lateral to the 4th rib. The average vertical location was 1.3 ± 0.9 cm from the superior border of the 4th rib. These data comment upon intraoperatively identified and consistent location of upper extremity lymphatic channels used for ILR. These lymphatic channels are often found in clusters with 2 or more lymphatic channels at the same location. Such insight may aid in easier intraoperative identification of amenable vessels for the unexperienced surgeon, decrease in intraoperative time, and higher success of ILR.

Development of a Modified Duodenum Traction Technique in Laparoscopic Duodenal Web Excision.

Introduction: Laparoscopic duodenal web resection surgery remains safe in neonates. The pearls in laparoscopic duodenal web excision are a proper and stable duodenal exposure. Herein, we present a modified duodenal traction technique, which can improve operative field exposure in laparoscopic surgery. Material and Methods: This modified technique was performed in 54 patients during laparoscopic duodenal web resection surgery at our center. It was performed using a 5-0 PDS-II suture, which was introduced percutaneously at 1-2 cm under either side of the costal margin at the anterior axillary line, respectively, to retract the duodenum. Results: Perioperative data of these patients and short-term follow-up data of duodenal web patients were retrospectively reviewed. All 54 procedures were completed without conversion to open surgery or requiring additional ports. Patients' mean age at surgery was 5 days (range 2-30 days), and the median weight at the time of surgery was 3.25 kg (range 2.52-3.88 kg). Eight patients (14.8%) had complete membranes, whereas 46 (85.2%) had a membrane with a hole. The mean time required for this technique was 336 (range 216-416) seconds and the mean duration of the entire surgery was 77 (range 65-89) minutes. The mean postoperative hospital stay was 16 (range 9-90) days and no postoperative complication related to the suspension procedure occurred. Conclusion: Our outcomes demonstrated the modified duodenal traction technique is a feasible and ideal method during laparoscopic duodenal web resection surgery.

The surgical anatomy of the axillary approach for nerve transfer procedures targeting the axillary nerve

PurposeThe exact relational anatomy for the anterior axillary approach, targeting the axillary nerve for nerve transfers/grafts, has not been fully investigated. Therefore, this study aimed to dissect and document the gross anatomy surrounding this approach, specifically regarding the axillary nerve and its branches.MethodsFifty-one formalin-fixed cadavers (98 axilla) were bilaterally dissected simulating the axillary approach. Measurements were taken to quantify distances between identifiable anatomical landmarks and relevant neurovascular structures encountered during this approach. The musculo-arterial triangle, described by Bertelli et al., to aid in identification on localization of the axillary nerve, was also assessed.ResultsFrom the origin of the axillary nerve till (1) latissimus dorsi was 62.3 ± 10.7 mm and till (2) its division into anterior and posterior branches was 38.8 ± 9.6 mm. The origin of the teres minor branch along the posterior division of the axillary nerve was recorded as 6.4 ± 2.9 mm in females and 7.4 ± 2.8 mm in males. The musculo-arterial triangle reliably identified the axillary nerve in only 60.2% of the sample.ConclusionThe results clearly demonstrate that the axillary nerve and its divisions can be easily identified with this approach. The proximal axillary nerve, however, was situated deep and therefore challenging to expose. The musculo-arterial triangle was relatively successful in localising the axillary nerve, however, more consistent landmarks such as the latissimus dorsi, subscapularis, and quadrangular space have been suggested. The axillary approach may serve as a reliable and safe method to reach the axillary nerve and its divisions, allowing for adequate exposure when considering a nerve transfer or graft.

MP32-07 SURGEON-ADMINISTERED ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCKS DURING RADICAL CYSTECTOMY: DESCRIPTION OF TECHNIQUE AND PERIOPERATIVE OPIOID REQUIREMENT

You have accessJournal of UrologyCME1 Apr 2023MP32-07 SURGEON-ADMINISTERED ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCKS DURING RADICAL CYSTECTOMY: DESCRIPTION OF TECHNIQUE AND PERIOPERATIVE OPIOID REQUIREMENT Justin Refugia, Hilary Brownstead, Parth Thakker, Randy Casals, Corey Able, Emily Roebuck, and Matvey Tsivian Justin RefugiaJustin Refugia More articles by this author , Hilary BrownsteadHilary Brownstead More articles by this author , Parth ThakkerParth Thakker More articles by this author , Randy CasalsRandy Casals More articles by this author , Corey AbleCorey Able More articles by this author , Emily RoebuckEmily Roebuck More articles by this author , and Matvey TsivianMatvey Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003265.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Implementation of standardized analgesic regimens is paramount to developing enhanced recovery after surgery (ERAS) protocols for radical cystectomy (RC). Transversus abdominis plane (TAP) blocks have demonstrated decreased length of stay (LOS) and perioperative opioid requirement. To date, no studies have reported on ultrasound (US) guided blocks performed by the surgeon in this setting. In this study, we present our technique for surgeon-administered, US-guided TAP (sUTAP) blocks and review postoperative opioid requirements. METHODS: We retrospectively reviewed patients that received sUTAP blocks just prior to incision for RC. The blocks were performed with US-guidance to advance the needle into the transversus abdominis plane at the anterior axillary line between the subcostal margin and iliac crest. Next, 25-cc of an anesthetic solution was instilled into this plane and the procedure was repeated on contralateral side (total of two injection sites). The primary objective was overall perioperative opioid requirement. Due to protocol changes, we also compared two groups of patients that received a 50-cc mixture of: 0.25% bupivacaine mixed with liposomal-bupivacaine (LB) or 0.25% bupivacaine only. Analyses were performed on demographics, surgical and anesthetic details, and perioperative medications. RESULTS: Between 2020 and 2022, we identified 47 patients that received sUTAP blocks during RC. The men (79%) had a median age of 70 years (IQR 61-75), and women (21%) had a median age 77 years (IQR 67-80). RC approach was open (81%) or robotic (19%). Urinary diversion was with ileal conduit (53%) or cutaneous ureterostomy (47%). Overall median perioperative MMEs: intraoperative – 85 (53-107), POD0 – 25 (15-45), POD1 – 15 (0-40), POD2 – 7.5 (0-25), POD3 – 2.5 (0-16), and POD4 – 0 (0-11). The overall median length of stay was 4 days (IQR 3-6). LB was included for 14 patients (30%) and intraoperative/POD1 MMEs were higher than the 33 patients (70%) that received bupivacaine only (p<0.05). CONCLUSIONS: Our results suggest that addition of sUTAP blocks may reduce postoperative opioid requirements. Learning our technique should be considered by surgeons that are developing ERAS protocols for RC. Further comparative studies between anesthesia-administered TAP blocks and other peri-operative regional pain management modalities may clarify efficacy of sUTAP. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e442 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Refugia More articles by this author Hilary Brownstead More articles by this author Parth Thakker More articles by this author Randy Casals More articles by this author Corey Able More articles by this author Emily Roebuck More articles by this author Matvey Tsivian More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract P2-14-12: Endoscopic Nipple-Sparing Mastectomy: A single Institutional Experience of 50 Consecutive Cases

Abstract Purpose: The purpose of this study is to to introduce an early experience of endoscopic nipple-sparing mastectomy (NSM) combined with immediate breast reconstruction through simple single-port access that placed in axillary incision. Methods and Materials: Between November 2018 and June 2022, 48 female patients with breast cancer, total 50 cases of breast cancer (bilateral breast cancer in 2 patients) were treated with endoscopic NSM combined with immediate breast reconstruction through simple single-port access that placed in axillary incision. Forty-six patients, total forty-eight cases, underwent breast reconstruction with silicone implant, two patient underwent TRAM reconstruction. Surgical procedures of endoscopic NSM: Patients were placed in a supine position with both upper limbs on arm boards abducted 90 degree. An incision of 5 cm was made along the anterior axillary line from the inferior mammary fold. The sentinel lymph node was excised through the incision. .A workspace for the insertion of a Glove Port (Nelis, Republic of Korea) was created within a radius of 3 cm from the incision, and the subcutaneous tissue flaps were raised. The Glove Port was inserted first into the retromammary space, carbon dioxide (CO2) gas was insufflated, and the pressure was maintained at approximately 7 mmHg. The retromammary space dissection was performed with caution to avoid dissecting the interpectoral space, using an energy device and an endoscopic grasper guided by a flexible endoscope (ENDOEYE FLEX 10 mm, OLYMPUS, Japan). The breast was elevated to the edge of the latissimus dorsi muscle laterally, to the thoracoabdominal aponeurosis inferiorly, to the level of the clavicle superiorly, and to the edge of the sternum medially. After dissecting the retromammary fat plane, the Glove Port was relocated into the subcutaneous space. Skin flap was dissected using an energy device, and the duct beneath the nipple was cut off using endoscopic scissors. The subcutaneous flap was dissected completely along the boundaries of the breast, and the entire breast was removed Results: The patients were 30-55 years old (mean, 43 years). The tumor located at the left breast in 26 cases and at the right breast in 23 cases. The diameter of tumor ranged from 1.5 to 5.2 cm (mean, 3.4 cm). Median operation time was 153 minutes. After operation, nipple necrosis or skin flap necrosis was not observed. No subcutaneous emphysema occurred. There is one tumor involvement to nipple in postoperative pathological examination. So, excision of nipple-areolar-complex was performed 2 weeks after first operation. All patients were followed up 1-43 months (median, 19 months). According to the Harris assessment criteria for appearance of reconstructed breast, there were 43 cases of excellent and 7 cases of good. No tumor recurrence or metastasis occurred during follow-up. Conclusion: It is a safe and feasible method of endoscopic NSM combined with immediate breast reconstruction through simple single-port access that placed in axillary incision, and can obtain good cosmetic results. It is a new option to breast reconstruction. Citation Format: HYEYOON LEE, Kyusang Cho, YOUNGWOO CHANG, GILSOO SON. Endoscopic Nipple-Sparing Mastectomy: A single Institutional Experience of 50 Consecutive Cases [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-12.

Surgical Correction of Massive Gynecomastia Using Power-Assisted Liposuction and Direct Gland Resection

Introduction: The surgical treatments of mild to moderate gynecomastia has evolved towards less invasive techniques, such as power-assisted liposuction, suction-assisted lipectomy or ultrasound-assisted liposuction. Excisional techniques are still indicated for the most severe cases characterized by skin excess and ptosis. The aim of this study was to present a method of using power-assisted liposuction combined with gland resection to treat gynecomastia with severe hypertrophy. Materials and Methods: We conducted a chart review of 27 consecutive patients treated for massive gynecomastia between 2014 and 2018. Power-assisted liposuction was performed to remove the fatty breast tissue. Incisions for liposuction were placed at lateral inframammary fold and upper anterior axillary pillar. An inferior hemiperiareolar incision was then performed to allow direct resection of fibroglaundular breast tissue. A final liposuction in all directions was performed again to recontour the breast. No skin was resected and drains were always inserted in each breast. Compression vest was worn for 6 weeks after surgery. Results: In average, 749 mg of fat and fibroglandular tissue were removed from each breast. No complications were reported. At 1 year follow-up, ideal aesthetic results, with minimal scars, adequate virilization of the chest contour and full satisfaction of surgeon and patient were observed in 24 patients, while 3 patients presented residual skin excess. Conclusion: In average, 749 mg of fat and fibroglandular tissue were removed from each breast. No complications were reported. At 1 year follow-up, ideal aesthetic results, with minimal scars, adequate virilization of the chest contour and full satisfaction of surgeon and patient were observed in 24 patients, while 3 patients presented residual skin excess.

A uniport subxiphoid approach with a modified sternum retractor is safe and feasible for anterior mediastinal tumors.

Minimally invasive surgery has been used to treat anterior mediastinal tumors. This study sought to describe a single team's experience of uniport subxiphoid mediastinal surgery using a modified sternum retractor. Patients who underwent uniport subxiphoid video-assisted thoracoscopic surgery (USVATS) or unilateral video-assisted thoracoscopic surgery (LVATS) from September 2018 to December 2021 were retrospectively enrolled in this study. A 5-cm vertical incision approximately 1-cm caudal to the xiphoid process was usually made followed by the installment of a modified retractor, which was able to raise the sternum by 6-8 cm. Next, the USVATS was performed. In the unilateral group, 3 1-cm incisions were usually made, among which, 2 are made in the 2nd or 3rd and 5th intercostal anterior axillary line, and the 3rd was made in the 5th intercostal midclavicular line. In some instances, an additional subxiphoid incision was made to remove the large tumors. All the clinical and perioperative data, including the prospectively recorded visual analogue scale (VAS) score, were analyzed. In total, 16 patients who underwent USVATS and 28 patients who underwent LVATS were enrolled in this study. With the exception of tumor size (USVATS 7.9±1.6 cm vs. LVATS 5.1±2.4 cm, P<0.001), the baseline data of the patients in the 2 groups were comparative. Blood loss in surgery, conversion, draining duration, postoperative stay, postoperative complications, pathology and tumor invasion were similar between the 2 groups. Although the operation time was significantly longer in the USVATS group than the LVATS group (115±19 vs. 83±30 min, P<0.001), the VAS score at 1st postoperative day (1.9±1.1 vs. 3.1±1.1, P<0.001) and moderate pain level (a VAS score >3) (6.3% vs. 32.1%, P=0.049) were better in the USVATS group than the LVATS group. Uniport subxiphoid mediastinal surgery is a feasible and safe procedure, especially for large tumors. Our modified sternum retractor is especially helpful during uniport subxiphoid surgery. Compared to lateral thoracic surgery, this approach has the advantages of less injury and lower postoperative pain, which may lead to a faster recovery. However, its long-term follow-up outcomes need to be observed.

The enhanced recovery after surgery (ERAS) protocol in elderly patients with acute cholecystitis: A retrospective study.

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

Upper Airway Stimulation in Female Patients: Safety and Efficacy of a Novel Lateral Approach.

To describe a novel lateral approach for hypoglossal nerve stimulator (HNS) implantation in women and provide evidence for its safety and efficacy. Retrospective case series. Single academic medical center. We identified patients implanted with HNS by a single surgeon from January 2017 to December 2021. Patient characteristics, postoperative complications, surgical duration, response to therapy, and need for revision surgery were recorded. One hundred four patients were included, including 93 males and 11 females. The lateral approach for HNS implantation involves placing the chest incision for the implantable pulse generator and respiratory sensor lead vertically in the anterior axillary line instead of horizontally in the infraclavicular area. No changes are made to the stimulator lead placement. All female patients were implanted using a lateral approach and all male patients were implanted via the standard anterior approach. Half of the patients were implanted via a 2-incision technique. The median surgical time duration was equivalent in male and female patients (119 [interquartile range (IQR): 105-138] vs 126 [IQR: 115-141], respectively). Revision was required in 2 (18%) females versus 6 (6%) males (p = .17). There were equivalent rates of therapy response as well as postoperative complications. A more cosmetic lateral approach is feasible for HNS in female patients and has a similar rate of adverse events and therapy responsiveness. Additional considerations in female patients include the ability to tolerate mammography as well as HNS implantation in the setting of existing breast implants.

ROLE OF SQUARE FLAP IN POST BURN AXILLARY CONTRACTURES

Background: Post-burn contractures are a commonly encountered problem and many techniques have been described in their treatment. Zplasties are the commonest local ap procedure done for linear bands with adjacent healthy tissue. Our aim was to assess the use of square ap technique in axillary contractures. Ten patients with type I and II axillary c Methods: ontractures underwent release by the square ap technique. All cases were followed up for at least one year and analysed for range of motion and aesthetic outcome. All cases achieved full range of Results: movement postoperatively with no recurrence during follow up period and a good cosmetic outcome. Square ap was shown to be a Conclusion: reliable technique for mild to moderate axillary contractures of the anterior or posterior axillary folds even when there is signicant adjacent scarring of chest wall or back of types I and II.

ACCURACY OF LUNG ULTRASOUND TO DIAGNOSE TRANSIENT TACHYPNEA OF NEWBORN

Objective: To find out the accuracy of lung ultrasound to diagnose transient tachypnea in neonates&#x0D; &#x0D; Methodology: Cross-sectional study at Neonatology Department, Sadiq Abbasi (Civil) Hospital Bahawalpur from January 2019 to October 2022 and comprised of neonates diagnosed as transient tachypnea of newborn admitted and were divided into 2 groups based on Chest radiograph findings comparable to each other in demographics. Lung Ultrasonography examinations were performed in all patients in a peaceful condition. Each lung was split up in three zones bounded by anterior axillary and posterior axillary lines as anterior, posterior and lateral. Lung Ultrasonography results compared with CXR findings. &#x0D; Results: Out of 148, Lung Ultrasonography diagnosed transient tachypnea of newborn in 74% while Chest radiograph was suggestive in 39% however, Lung Ultrasonography was also diagnosed i.e. 61% transient tachypnea of newborn in neonates having normal Chest radiograph examination. The commonest Lung Ultrasonography indexes of transient tachypnea of newborn were A-lines abnormalities 100%, B-lines abnormalities 94.5 %, interstitial syndromes 81.6%, white lungs 36.6%, double lung point 86.77%, consolidation 21% and pleural effusions 10%. The sensitivity of LUS to diagnose transient tachypnea of newborn was 86.5% and the sensitivity and the specificity of Double Lung Point to diagnose transient tachypnea of newborn were 92.2% and 80% respectively.&#x0D; Conclusion: Lung Ultrasonography is a noninvasive way of bedside neonatal examination. It has analytic value to diagnose lung disease in neonates but also helps in differentiation of different lung diseases with no radiation hazard.&#x0D; Keywords: Neonatology, Fetal lung fluid, transient tachypnea of newborn, Dyspnea, Neonatal Lung Ultrasound

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Mitral Valve Surgery-A Propensity Matched Competitive Analysis.

Background and Objectives: Transaxillary access is a straightforward “single incision—direct vision” concept, based on a 5 cm skin incision in the right anterior axillary line. It is suitable for aortic, mitral and tricuspid surgery. The present study evaluates the hospital outcomes of the transaxillary access for isolated mitral valve surgery compared with full sternotomy. Patients and Methods: The final study group included 480 patients. A total of 160 consecutive transaxillary patients served as treatment group (MICS-MITRAL). Based on a multivariate logistic regression model including age, sex, body-mass-index, EuroScore II and LVEF, a 1:2 propensity matched control-group (n = 320) was generated out of 980 consecutive sternotomy patients. Redo surgeries, endocarditis or combined procedures were excluded. The mean age was 66.6 ± 10.6 years, 48.6% (n = 234) were female. EuroSCORE II averaged 1.98 ± 1.4%. Results: MICS-MITRAL had longer perfusion (88.7 ± 26.6 min vs. 68.7 ± 32.7 min; p < 0.01) and cross-clamp (64.4 ± 22.3 min vs. 49.7 ± 22.4 min; p < 0.01) times. This did not translate into longer procedure times (132 ± 31 min vs. 131 ± 46 min; p = 0.76). Both groups showed low rates of failed repair (MICS-MITRAL: n = 6/160; 3.75%; Sternotomy: n = 10/320; 3.1%; p = 0.31). MICS-MITRAL had lower transfusion rates (p ≤ 0.001), less re-exploration for bleeding (p = 0.04), shorter ventilation times (p = 0.02), shorter ICU-stay (p = 0.05), less postoperative hemofiltration (p < 0.01) compared to sternotomy patients. No difference was seen in the incidence of stroke (p = 0.47) and postoperative delirium (p = 0.89). Hospital mortality was significantly lower in MICS-MITRAL patients (0.0% vs. 3.4%; p = 0.02). Conclusions: The transaxillary access for MICS-MITRAL provides superior cosmetics and excellent clinical outcomes. It can be performed at least as safely and in the same time frame as conventional mitral surgery by sternotomy.

Injuries of the Pectoralis Major: Diagnosis and Management.

Pectoralis major ruptures are uncommon injuries that have become more prevalent over the past 20 years due to increased participation in weight lifting. Patients often present with localized swelling and ecchymosis, muscular deformity, thinning of the anterior axillary fold, and weakness in adduction and internal rotation of the affected arm. History and physical is often augmented with radiology, magnetic resonance imaging of the chest being the gold standard. Nonoperative management is reserved for old patients with low functional demands. Operative intervention is the treatment of choice with improved functional outcomes, cosmesis, and patient satisfaction.

MONITORING OF PULMONARY EDEMA USING ULTRASOUND RADIOFREQUENCY SIGNAL.

Objectives: Excessive accumulation of extravascular lung water impairs respiratory gas exchange and results in respiratory distress. Real-time radiofrequency signals of ultrasound can continuously and quantitatively monitor excessive lung water. This study aims to evaluate the availability of continuous real-time quantitative pulmonary edema monitoring using ultrasound radiofrequency signals and compare it with Pa o2 (partial pressure of arterial oxygen)/F io2 (fraction of inspired oxygen) (PF) ratio, conventional lung ultrasound, and the Hounsfield unit of chest computed tomography. Methods: Male Yorkshire pigs (40.5 ± 0.5 kg) were anesthetized and mechanically ventilated. A balanced crystalloid was administered to induce hydrostatic pulmonary edema. Three different infusion rates of 2, 4, and 6 mL/kg per minute were tested to determine the infusion rate for the appropriate swine model. The chest computed tomography and ultrasonography with radiofrequency signals were taken every 5 min during the full inspiration. The ultrasonography scans with radiofrequency signals were measured at the intercostal space where the line crossing the two armpits and the right anterior axillary line intersected. Results: The infusion rate of fluid for the pulmonary edema model was determined to be 6 mL/kg per minute, and a total of four pigs were tested at an injection rate of 6 mL/kg. The adjusted R2 values of regression analysis between the radiofrequency signal and computer tomography Hounsfield score were 0.990, 0.993, 0.988, and 0.993 (all P values <0.05). All radiofrequency signal changes preceded changes in PF ratio or lung ultrasound changes. The area under the receiver operating characteristic curve of the radiofrequency signal for predicting PF ratio <300 was 0.88 (95% confidence interval, 0.82-0.93). Conclusion: We evaluated ultrasound radiofrequency signals to assess pulmonary edema in a swine model that can worsen gradually and showed that quantitative ultrasound radiofrequency signal analysis could assess pulmonary edema and its progression before PF ratio or lung ultrasound changes.

Sutureless Aortic Valve Replacement Through Lateral Mini-Thoracotomy - Feasibility and Effectiveness.

Minimally invasive sutureless aortic valve replacement with the Perceval bioprosthetic heart valve (MISUAVR) is commonly performed through a right anterior thoracotomy (AT). However, a lateral thoracotomy (LT) may be superior as it does not require rib and right internal thoracic artery (RITA) cutting.Methods and Results: In total, 38 MISUAVRs performed from May 2019 to approximately August 2021 were retrospectively reviewed; 21 through LT (Group L), and 17 through AT (Group A). In Group L, the skin incision was made on the right anterior axillary line and third intercostal space, and in group A, on the right anterior chest and second or third intercostal space. All other surgical techniques were the same. Age, body surface area, EuroSCORE II, and ejection fraction were similar between the patients. Cardiopulmonary bypass (L: 82±19 vs. A: 93±28 min, P=0.19) and cross-clamp times (L: 57±13, vs. A: 64±23 min, P=0.19) were similar. Rib and/or RITA cutting were required in 94.6% of patients in group A and in none of group L (P<0.001). Surgical visualization score was better in group L (L: 1.19±0.40 vs. A: 1.94±0.69, P<0.01). Total amount of intraoperative bleeding was lower in group L (L: 623±141 vs. A: 838±316 mL, P<0.01). Duration of hospital stay was similar (P=0.30). MISUAVR through LT has multiple advantages over AT.