Anterolateral Thoracotomy Research Articles

Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study

ObjectiveThe primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects. DesignSingle-center, prospective, observational study. Recruitment between December 2017 and August 2018. SettingPerioperative care at university-affiliated tertiary care centre. Patients202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded. InterventionsThoracotomy (n = 106) and sternotomy (n = 96). MeasurementsPain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire. Main resultsIncidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects. ConclusionsOur study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.

Aortic valve replacement via right anterolateral minithoracotomy: preventing adverse events during the initial learning curve

Despite excellent outcomes and reduced invasiveness, the right anterolateral thoracotomy approach for aortic valve replacement (RALT-AVR) has not been broadly adopted. This study provides results regarding the initial experience and learning curve of a single surgeon performing this procedure. Periprocedural details and postoperative outcomes of the first 100 consecutive patients who underwent RALT-AVR at our institution were retrospectively analyzed. We conducted a cumulative sum analysis of surgical failure, defined as occurrence of 30-day-mortality, surgical revision for bleeding, conversion to sternotomy, 3rd degree heart block, paravalvular leakage, postoperative stroke or mean transvalvular gradient >20 mmHg. The cohort was of low surgical risk (mean EuroSCORE II 1.31%±0.85, mean STS PROM 1.45%±0.97), 58% were males. Median cross-clamp time was 67.5 (57.8-76) min, median CPB time 105 (91.8-119) min, and median operation time 164.5 (144.5-183.2) min. There were no conversions to full sternotomy, 4 cases of revision for bleeding and 2 pacemaker implantations for 3rd degree heart block. Prosthesis function was good (median ΔPmean 10.9 [7.4-13.6] mmHg). Thirty-day-mortality was 0%. The log-likelihood graph never crossed the upper boundary, and after a steady decrease, crossed the lower boundary at 93 patients. RALT-AVR can be performed with acceptable procedural times and satisfactory outcomes. For a well-trained surgeon, adapting to this new procedure does not expose patients to an increased risk, when patient selection and procedural planning are applied appropriately. Cumulative sum failure analysis is an appropriate tool to monitor the transition from standard AVR to the technically more demanding RALT-AVR.

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Demographic and Surgical Profile of the Patients Underwent Minimally Invasive Cardiac Surgery in a Rural Center of Bangladesh

Background: Ever Since its inception , minimally invasive cardiac surgery is growing rapidly for better convenience and superb post operative outcome. As newer instruments, surgical technique and operative exposure are increasing more and more patients are demanding minimally invasive cardiac surgery. Objective: The study was conducted to evaluate the various pre operative and peroperative factors in minimally invasive cardiac surgery. Materials and Methods: A retrospective observational study on the patients who underwent minimally invasive cardiac surgery in the department of cardiovascular and thoracic surgery, Khwaja Yunus Ali Medical College, Sirajganj, Bangladesh from January 2016 to December 2020. Results: A total of 40 cases were operated through minimally invasive cardiac surgery in our department. Maximum number of cases was Atrial septal defect(ASD), and minimally invasive direct coronary artery bypass (MIDCAB). About 62.50% were female, majority of patients were in the range of 11-15 years. Right anterolateral thoracotomy was done in 27 cases and left anterolateral thoracotomy in 10 cases. The maximum number of cannulation done in femoral artery and femoral vein, followed by direct superior vena caval cannulation and only a single percutaneous superior venacaval cannulation through internal jugular vein. In 14 cases the length of incision was in the range of 3-4 cm and 12 cases in 4-5cm. Conclusion: Minimally invasive cardiac surgery is now becoming more demanding. As more and more centers are opening the door to newer technology, common people are also becoming conscious about its excellent post operative outcome. KYAMC Journal.2021;12(02): 71-74

Bilateral lobar lung transplantation and a single lung transplantation using lungs from a single organ donor during coronavirus disease 2019 pandemic.

Bilateral lobar lung transplantation and a single lung transplantation using lungs from a single organ donor during coronavirus disease 2019 pandemic.

Solving the impossible. Penetrating cardiac injuries, a case series of diagnostic workup and management

For a long time, any heart-based injury was an off-limits area for surgeons; a patient with a traumatic cardiac injury was doomed to die. Little more than one hundred years have passed since the first surgical correction of a penetrating cardiac injury and there is still a high rate of mortality, despite the medical advances. We present the case of 6 patients with penetrating cardiac injuries that were repaired at a third level hospital of Mexico, alongside relevant findings on the literature about the topic. From 2019 to 2020, an incidence of 6 patients with penetrating cardiac injuries was present; all men aged 30 years or older. The etiology of 4 (67%) patients was stab wounds and 2 (33%) gunshot wounds. Left anterolateral thoracotomy was used on 5 (83%) patients and midline sternotomy on 1 (17%) patient. 2 (33%) injuries on the left ventricle presented along with coronary arteries injuries. Left ventricle and right atrium injuries presented each 50% of mortality. The mortality was of 33%, 1 patient died due to intraoperative complications and another one due to massive cerebral infarction and polyuric syndrome because of diabetes insipidus. There is a long path ahead of the surgical field on this topic and further to be analyzed. An excellent tool for cardiac tamponade diagnosis due to penetrating cardiac injuries is cardiac ultrasound, therefore it should be used on every hemodynamic unstable patient in the context of PCI. Definitively, time is of the essence, and the survival of patients depends on immediate transport to a hospital and an opportune surgical intervention.

Reoperative Mitral Valve Surgery Through Port Access

Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR < 60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature.

Early cardiac contractility outcome of reoperative coronary artery bypass grafting using right gastroepiploic artery.

Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

Right Anterolateral Thoracotomy Versus Sternotomy for Resection of Benign Atrial Masses: A Systematic Review and Meta-Analysis.

Primary benign cardiac tumors are rare disease entity that predominantly originate from the atria. Benign masses can induce heart failure, arrhythmia, or thromboembolic events. Therefore, surgical excision is often indicated. Current guidelines on the preferred approaches for resection (i.e., median sternotomy [MST] or right anterolateral thoracotomy [RAT]) are lacking. The aim of the current meta-analysis was to evaluate all studies comparing RAT to MST for excision of benign atrial masses in terms of safety, efficacy, and complications. The PubMed and EMBASE databases were searched through 9 June 2020. Data regarding mortality, complications, recurrence, ICU stay, and length of hospital stay were extracted and submitted to meta-analysis using random effects modelling. Heterogeneity was assessed by the I 2 test. Four retrospective observational studies were included, including 196 patients (RAT n = 97, MST n = 99). Mortality was 0% in both groups. Recurrence was <1% in the RAT group and 0% in the MST group. Complication rate tended to be lower in favor of the RAT group. Furthermore, RAT was associated with lower length of ICU stay (-17.7 hr, P = 0.01) and hospital stay (-4.0 days, P < 0.001). No significant differences in cardiopulmonary bypass (P = 0.09) and cross-clamp times (P = 0.15) were observed. The RAT approach is as safe and effective as MST for the excision of benign atrial masses. Moreover, RAT is associated with a reduced complication rate and a reduced duration of hospitalization and could be considered as the preferred approach in anatomically suitable patients.

Pulmonary Echinococcosis Surgery

We present an analysis of the results of surgical treatment of 182 patients with pulmonary echinococcosis (126 patients with uncomplicated and 56 with complicated pulmonary echinococcosis). Of these, only in 23 patients out of 25 planned, it was possible to carry out echinococcectomy purely thoracoscopically through trocar punctures. In 134 cases, videothoracoscopic echinococectomy was performed using a mini-access. In case of bilateral localization of cysts, stage-by-stage operations were performed in 7 patients, and in 3 (36.36%) cases - single-stage echinococcectomy. Echinococcectomy from the lung was performed in 25 patients using a wide thoracotomy approach. In 134 cases, videothoracoscopic echinococectomy was performed using a mini-access. In case of bilateral localization of cysts, stage-by-stage operations were performed in 7 patients, and in 3 (36.36%) cases - single-stage echinococcectomy. Echinococcectomy from the lung was performed in 25 patients using a wide thoracotomy approach. All patients underwent anterolateral thoracotomy. Basically (97.67%) performed organ-preserving operations with the elimination of the residual cavity in the light suture plastics in various modifications. In 2 patients with marginal location and pneumocirrhosis, marginal resection of the lung with an echinococcal cyst was performed.With combined echinococcosis of the lungs and liver, 10 patients were operated on. 6 patients underwent surgical interventions on the lungs and liver through separate approaches at the same time. The use of minimally invasive techniques for pulmonary echinococcosis is possible in more than 2/3 of patients.

Carinal sleeve resection: last exit for bronchial insufficiency-a 17-year, single-centre experience.

Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina. All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice. A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days. Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Off-Pump Implant Strategy for the Jarvik 2000 LVAD

Purpose Median sternotomy and cardiopulmonary bypass (CPB) represent the gold standard for the left ventricular assist device (LVAD) implantation. Long-term survival rates in LVAD patients are highly dependent on the immediate peri- and post-operative course. The CPB deleterious effects in this fragile population include right ventricular dysfunction, bleeding, and end-organ injury. Minimally invasive strategies, with off-pump implantation and alternative access rather than sternotomy, have been recently reported for contemporary continuous-flow LVAD placement.We sought to assess the safety, feasibility, and short-term outcomes of minimally invasive off-pump LVAD implantation. Methods We retrospectively reviewed data of 19 patients who underwent off-pump Jarvik 2000 LVAD implantation, as destination therapy, from December 2010 to April 2019, at our center. The surgical access was: J-ministernotomy + left minithoracotomy in 89.5%, and anterolateral thoracotomy in 10.5% of the patients. Study endpoints were perioperative outcomes and long-term survival. Results Mean age was 67.1±5.2 years, 89.5 % were male and the underlying disease was ischemic cardiomyopathy in 42.1%. INTERMACS class was: II: 10.5%, III: 31.6%, IV: 57.9%. There were no on-pump conversions; a major bleeding required a surgical access conversion in 2 cases. Mean mechanical ventilation time was 17±7 hours, median of blood transfusion units was 6 (interquartile range 3-15). Perioperative stroke, bleeding requiring surgical re-entry and severe right ventricular failure were 5.2%, 21.1%, and zero, respectively. Median postoperative hospital stay was 30 days (interquartile range 21.5-45) with a 5.2% 30-day mortality rate. Mean duration of support was 1034.7 days (range 8-1981 days). Three patients had LVAD-related complications leading to device explant, after a mean time of 983±310 days: two patients underwent a re-do LVAD exchange, one was successfully transplanted. One- and 2-year overall survival were 77.8% ± 9.8% and 70% ± 11.5%, respectively. Conclusion Our preliminary experience shows that off-pump Jarvik 2000 LVAD implantation is feasible and safe alternative to the standard implantation technique. Good peri-operative outcomes and long-term survival rates could encourage an extended use of this strategy. However, additional implants and comparison of outcomes in larger populations are needed.

Effects of Surgical Left Ventricular Vent in Patients with Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

Purpose Venoarterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of cardiogenic shock often requires left ventricular (LV) venting to decrease afterload and prevent LV distention. Percutaneous strategies for LV venting are limited by peripheral complications such as bleeding and lower limb ischemia as well as insufficient LV unloading. A surgical LV vent is an alternative option that may provide hemodynamic and clinical benefits. Methods This is a retrospective review of 33 patients with refractory cardiogenic shock requiring VA ECMO who underwent surgical LV vent placement between July 2015 and March 2020. Surgical LV vent was placed in the LV apex via left anterolateral thoracotomy. Patients were stratified according to the percutaneous vent strategy prior to LV vent placement, which included femoral VA ECMO alone (n = 7), ECMO plus intra-aortic balloon pump (IABP) (n = 10), or ECMO plus Impella (ECPELLA) (n = 16) sub-groups. The outcome of interest was immediate hemodynamic change with surgical LV vent placement as well as clinical outcomes. Results The most cited reasons for conversion to surgical LV vent included inadequate venting with percutaneous strategy, hypoxia, and bleeding from peripheral access site. Across all patients, surgical LV vent was associated with a decrease in diastolic pulmonary artery (PA) pressures (20 vs 16 mmHg, p = 0.01) along with an increase in SVO2 (69% vs 80.5%, p Conclusion The surgical LV vent can provide significant LV unloading in patients supported by VA ECMO for cardiogenic shock. Compared to percutaneous methods of LV unloading, the surgical LV vent can provide substantial unloading of the LV, improved oxygenation, and a greater degree of hemodynamic support with acceptable short-term outcomes.

Extensive rib resection followed by thoracic wall reconstruction using polytetrafluoroethylene mesh and titanium plates for refractory intercostal artery bleeding induced by severe blunt thoracic injury: report of a case.

Massive hemothorax due to multiple rib fractures and intercostal artery (ICA) injuries is one of the most lethal forms of chest trauma. Urgent thoracotomy is required; however, suturing is sometimes difficult owing to the limited operative field in the thoracic cavity and because the transected ICA retracts between the surrounding intercostal muscles. We present a patient with refractory ICA bleeding induced by severe blunt thoracic injury successfully treated with extensive rib resection followed by thoracic wall reconstruction using GORE® DUALMESH® and titanium plates. A 66-year-old woman attempted suicide by diving into the path of a train. She incurred massive left hemothorax associated with multiple rib fractures and severe trauma to her extremities; both upper limbs and left leg at the thigh were nearly disconnected. Initially, she underwent urgent left anterolateral thoracotomy followed by partial lung resection and suture hemostasis of the thoracic wall. Subsequently, interventional radiology was performed for the ICA bleeding, and her extremities except her right leg were amputated. However, because hemothorax persisted, and because of the comminuted fractures, we removed the fifth to eighth ribs, and the ICA vascular sheath was ligated. Resecting multiple ribs caused deformities and lung herniations, although hemostasis was achieved. On the third postoperative day, thoracic reconstruction using Gore-Tex® Dual Mesh and titanium plates was performed. Although a small empyema occurred, it was controlled with antibiotics and drainage. Paradoxical respiration and atelectasis did not occur, and the patient was moved to the hospital for continued care in a lucid state.

Fusion of Bovine Tissue Aortic Valve Leaflets in a Patient with Left Ventricular Assist Device: A Case Report

<h3>Introduction</h3> We present a case of a patient with prior bioprosthetic aortic valve replacement who underwent Left Ventricular Assist Device (LVAD) explant and was found to have fused valve leaflets at the time of surgery. <h3>Case Report</h3> The patient is a 30 year old woman with a history of a congenital quadricuspid aortic valve (frequency < 0.05%), complicated by myocardial infarction and cardiogenic shock with LVEF 5% due to occlusion of the left main coronary ostium by rupture of one of the leaflets. She required support via Veno-Arterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) followed by Aortic Valve Replacement with #23 Bovine Tissue Valve and HeartMate 3™ (Abbot Laboratories) implantation in January 2019. Her LVEF improved to 55% after 6 months of mechanical circulatory support. The patient was scheduled for LVAD explant 9 months after implant. Intraoperative transesophageal echocardiogram showed leaflet fibrosis & severe functional closure of her prosthetic aortic valve and left ventricular outflow tract, not seen on prior echocardiograms (Figure 1). We performed an LVAD explant via redo sternotomy and left anterolateral thoracotomy, redo-aortic valve replacement with a #19 mechanical valve, and ventriculotomy closure using custom made synthetic plug. She is doing well 13 months after surgery. <h3>Summary</h3> Patients with prior tissue aortic valve replacement require careful preoperative evaluation before LVAD explant. Though we had a good outcome, pre-procedural knowledge of valve dysfunction is critical in surgical planning. We have developed an algorithm which may be utilized in the future to improve outcomes (Figure 2).

Left Ventricular Assist Device Exchange to HeartMate III Using Minimally Invasive Approach

<h3>Purpose</h3> Pump thrombosis, infection or device malfunction are major complications of LVAD that may need to be treated with pump exchange. There is limited data on exchanges to HMIII. Our purpose was to review outcomes of patients undergoing any LVAD to HMIII exchange at our center using minimally invasive approach (subcostal and/or left anterolateral thoracotomy). <h3>Methods</h3> We retrospectively reviewed records of patients undergoing any LVAD to HMIII exchange from January 2016 to October 2020. Pre-operative characteristics, indication, hospitalization course and post discharge data was collected. <h3>Results</h3> Ten patients underwent LVAD (7 HMII, 2 HMIII, 1 HeartWare) to HMIII exchange. Baseline characteristics are described in Table 1. Indications for exchange were pump thrombosis (3), infection + thrombosis (2), malposition (1), malposition + thrombosis (1), outflow graft obstruction from external compression (1), outflow graft twisting and thrombosis (1) and drive line injury (1). All patients underwent minimally invasive approach but 5 needed additional sternotomy to clear abscess collection or due to anatomical complexity. Post exchange, 1 patient needed pericardial window, 1 needed short term hemodialysis, 1 had recurrence of GI bleeding, 1 had CVA on POD 1 and 3 patients needed washout and debridement or hematoma evacuation. There was no change in RV function. Mean length of stay was 20.8 ±2 days. There was only 1 re-admission (sternal wound drainage needing debridement) within 30 days of discharge. There were a total of 8 other admissions (2 for MSSA Bacteremia, 1 for HF exacerbation, 1 for GI bleeding, 1 repeat debridement of sternal wound, 1 for renal failure and 2 for unrelated reasons) within 1 year post discharge. There was no recurrence of thrombosis. Mortality was 0% at 30 days and 0% at 1 year for 5/10 patients (others are alive and less than 1 year from exchange). <h3>Conclusion</h3> LVAD to HMIII exchange with a minimally invasive approach has low surgical mortality and acceptable intermediate- term outcomes.

Laser enucleation of a renal cell carcinoma (RCC) lung metastasis. This video demonstrates a metastasis enucleation using a laser fiber with a power of 60 W. The 64-year-old former heavy smoker male with a history of RCC 18 months prior, was admitted with undefined pulmonary nodules. The procedure started with a uniportal video-assisted thoracic surgery (VATS) wedge resection from segment

Laser enucleation of a renal cell carcinoma (RCC) lung metastasis. This video demonstrates a metastasis enucleation using a laser fiber with a power of 60 W. The 64-year-old former heavy smoker male with a history of RCC 18 months prior, was admitted with undefined pulmonary nodules. The procedure started with a uniportal video-assisted thoracic surgery (VATS) wedge resection from segment

Minimally Invasive Aortic Valve Replacement through Right Antero-Lateral Thoracotomy

Minimally Invasive Aortic Valve Replacement through Right Antero-Lateral Thoracotomy

Hemi-Clamshell Approach for Fetal Lung Interstitial Tumor Resection in a Neonate: A Case Report

Fetal lung interstitial tumor (FLIT) is a rare primary lung mass in neonates. Classical incisions, such as posterolateral thoracotomy or median sternotomy, do not provide optimal exposure of the operative field for the resection of pediatric thoracic giant tumors. Herein, we report a rare case of a FLIT in a full-term male neonate, with complete resection achieved using a hemi-clamshell approach, which provided the required visualization of the operative field. The neonate was transferred to our hospital because of mild respiratory distress, which developed 18-hour after normal vaginal delivery. A mass in his right chest, without a midline shift, was observed on chest radiographs. Computed tomography showed a well-circumscribed solid anterior cervicothoracic mass, with a uniform density and no apparent cysts, diagnosed as a primary thoracic giant tumor. Once the patient was clinically stabilized, we proceeded with right upper lobectomy, using a hemi-clamshell approach, full sternotomy, and anterolateral thoracotomy, on postnatal day 22.Histopathologic examination revealed an 8.5 × 6.5 × 4.0 cm solid mass within the right upper lobe, which was diagnosed as a FLIT. His postoperative recovery was uneventful. The patient was followed up for 1 year, with no complaints or symptoms and no postoperative shoulder dysfunction. Gross total resection of primary thoracic giant tumors can be accomplished in neonates with optimal exposure of the chest cavity using a hemi-clamshell approach.

Extraction of a bullet floating in the pulmonary artery after a gunshot wound.

BackgroundPatients with thoracic trauma caused by gunshots face a high risk of death, and medical staff often encounter technical difficulties in resolving these cases. Most gunshot wounds result in an entrance and exit wound. In cases with no exit wound, missiles are seen in other areas with screening radiographs. The bullet may migrate depending on gravity, coughing, swallowing, blood flow, or local erosion.Case presentationWe present the case of a teenager who was hospitalized in critical condition owing to a left hemithorax injury caused by an improvised explosive device. The patient underwent two surgeries: an anterior left thoracotomy during which a hole in the myocardium was sutured, and after radiography, anterolateral right thoracotomy was performed, in which a deformed projectile was found at the level of the intermediate right pulmonary artery.ConclusionsThis case highlights the crucial importance of repeated imaging to assess the possibility of projectile migration within the cardiovascular system in similar cases of penetrating injury. Immediate surgery was necessary and very important for the survival of our patient, despite the difficulties presented by this complicated case.