Left Posterolateral Thoracotomy Research Articles

EComment. Surgical management of coronary-to-pulmonary artery fistulas

Yamamoto and colleagues have described the successful surgical treatment of a patient with bilateral coronary-to-pulmonary artery fistulas [1]. We agree with their decision of opening the main pulmonary artery (PA) under CPB and closure of both orifices with a suture [1]. We reported this additional manoeuvre of opening the PA for the direct identification of the entry points of all the fistulas into the PA plus the securing of its closure with a patch of autologous pericardium, sealed with Bioglue for the avoidance of recurrence and it seems to be a very helpful technique [2]. Biorck and Crafoord, on the 22nd of July 1946, in the Surgical Clinic I at Sabbatsberg Hospital in Stockholm, performed the first successful surgical ligation of a pulmonary-to-coronary artery fistula. The patient was a 15-year-old male who was referred due to exertional dyspnoea, fatigue and a ‘continuous’ murmur over the pulmonary area. The primary diagnosis after radiographic and phonocardiographic findings was of a case of patent ductus arteriosus Botalli [3]. For this reason the patient underwent left postero-lateral thoracotomy by the method of Crafoord (according to the authors) with a removal of the fifth rib [3]. However, in the area of ductus arteriosus no thrill was palpable and further exploration revealed an arteriovenous aneurysm on the PA which was consistent with an arteriovenous communication between an aneurysm of an aberrant branch of the left coronary artery and the PA [3]. The authors applied and tightened a silk ligature for 3–4 minutes around the abnormal artery centrally to the aneurysm for observation of the reaction of the heart. No abnormalities in the cardiac function were noted and the silk ligature was tied. On direct auscultation with a sterile stethoscope the murmur had then decreased significantly. The authors applied another silk ligature distally now to the aneurysm and, thereafter, the continuous murmur disappeared. The pericardium and chest were closed with no drains and the patient had an uneventful recovery with significant improvement in his functional status (no dyspnoea on moderate exertion) when he was reviewed in November 1946 [3]. According to Angelini and colleagues, coronary artery anomalies (including coronary arteriovenous fistulas) appear quite frequently in the practice of cardiologists and cardiac surgeons. In addition, the coronary artery anomalies display a variety of anatomic variants, sizes, and clinical symptoms with different implications in all spectrums of ages [4]. It is very important to bear in mind that, according to the Sudden Death Committee of the American Heart Association, a 19% of deaths in athletes is related to coronary artery anomalies [5]. The multidisplinary approach is of paramount importance for all these patients. The type of treatment of most of the subgroups of coronary artery anomalies is not supported by evidence-based guidelines [4]. A careful assessment is needed to clarify who of those patients should be under close follow-up and who will be treated in the catheterization laboratory (use of vascular plugs, umbrella devices, covered stents or coils) or in the theatre (TOE, on/off CPB, plus/minus CABG). Conflict of interest: none declared.

Managing Severe Upper Extremity Ischemia from Mobile Aortic Arch Thrombus: A Novel Approach Using Isolated Limb Perfusion with Tissue Plasminogen Activator

Etiologies of upper extremity ischemia are numerous and include embolic aortic pathology. Traditional operative management for this entity includes open thrombectomy, catheter directed thrombolysis and/or percutaneous mechanical thrombectomy. These conventional options, however, may not be ideal for patients having unstable aortic arch thrombus and profound distal arterial thrombosis of the hand. An alternative approach for such patients is isolated limb perfusion (ILP) with tissue plasminogen activator (tPA). A 37-year-old female presented with sudden onset acute left hand ischemia associated with sensory and motor deficits. An axillary pulse was present and distal pulses were absent as were radial, ulnar and palmar signals. Her medical history was unremarkable but she was a 1 pack/day smoker. Her evaluation included a chest CT-angiogram showing a pedunculated aortic arch thrombus that was confirmed on transthoracic echocardiogram (TTE) and was mobile (Fig 1). Her hand ischemia was presumed to be caused by an embolus originating from the aortic arch. Given the severity of distal forearm and hand ischemia with the presence of mobile aortic thrombus, catheter directed thrombolysis was felt to be contraindicated and the patient was taken to the operating room (OR) for emergent brachial, radial and ulnar thrombectomy. This yielded some thrombus; however, an intraoperative angiogram (Fig 2, A) post-thrombectomy still showed significant residual hand thrombus with absent radial, ulnar and palmar signals. Further thrombectomy was felt to be ineffective and ILP with tPA was felt to be most appropriate. A perfusion circuit was constructed and connected to the patient via brachial artery and vein cannulas. A proximal arm tourniquet was placed. The perfusate was charged with 25 mg tPA/hour for a total circulation time of 2 hours at a flow rate of 200 cc/min. Fibrinogen levels remain unchanged during perfusion. After completing perfusion, a repeat angiogram (Fig 2, B) was performed showing marked thrombus resolution. The cannula sites and incision were closed. The patient then underwent left postero-lateral thoracotomy and open aortic thrombectomy without cardiopulmonary bypass. At 6 months follow-up, radial and ulnar pulses are present and without sensory or motor hand deficits. Prompt open surgical thrombectomy remains first line therapy for cases of acute severe upper extremity ischemia due to thromboembolism although it may be ineffective for distal arterial bed thrombus. Alternatively, catheter-directed thrombolysis is effective for distal bed thrombus. However, this is precluded in advanced ischemia and when systemic tPA exposure is contraindicated due to risk of further embolization from proximal thrombus. ILP with tPA allows for rapid distal bed thrombolysis while theoretically limiting systemic exposure. In circumstances where perfusion circuits are readily available, it is possible to utilize ILP with tPA as an alternative strategy when conventional treatment methods are deemed to be suboptimal.

Acute Respiratory Distress Caused by a Giant Mediastinal Lipoblastoma in a 16-Month-old Boy

Lipoblastoma is a rare benign tumor arising from embryonic fat; it occurs mainly in the extremities and almost exclusively in infants and children younger than 3 years. We present a case of giant mediastinal lipoblastoma in a 16-month-old boy who presented with acute respiratory distress. The mass was completely excised through a left posterolateral thoracotomy. The postoperative course was uneventful, and the pathologic final diagnosis was lipoblastoma. Although extremely rare, mediastinal lipoblastoma can be life threatening; therefore, it should be included in the differential diagnosis of mediastinal mass in younger subjects.

Herniation of the stomach and colon into the right hemithorax following a transthoracic Collis-Belsey operation

Collis gastroplasty and Belsey fundoplication is a good choice for patients with a large hiatal hernia and associated reflux. In this article, we report a patient who presented as post-emetic with herniation of the stomach and colon into the right hemithorax, within two months after the Collis Belsey procedure. The patient was reoperated on, and the hernia was reduced through a left posterolateral thoracotomy. At the 22-month follow-up, the patient was well and was able to tolerate a full diet without any symptoms.

Giant ganglioneuroma of the posterior mediastinum

We report the case of a 45-year-old female referred to us with progressive shortness of breath and a huge left mediastinal mass. Computed tomography of the chest revealed a mass occupying the posterior mediastinum and extending from the apex caudally to the left hemidiaphragm. Further magnetic resonance imaging demonstrated tumor extension to the left interverteberal foramina of T5-T6 and T6-T7. Excision of the mass was performed through a left posterolateral thoracotomy. Histology confirmed a mediastinal ganglioneuroma. This is an unusual tumor with more than one extension in the spine. Ganglioneuromas are rare tumors of the peripheral nervous system. Most of these tumors are, however, retroperitoneal and are more common in children and young adults. Ganglioneuromas arise from neural crest cells. These tumors are mostly asymptomatic, but some may present with hypertension and flushing. Massive tumors can present with pressure symptoms.

Postoperative paraplegia after resection of a giant posterior mediastinal tumour. Importance of the blood supply in the upper spinal cord☆

A 10-cm diameter tumour was revealed in the left upper posterior mediastinum in a 15-year-old female. After exclusion of the possibility of a dumbbell tumour and confirmation of a ganglioneurinoma, an encapsulated, but vascularised tumour was removed via a left posterolateral thoracotomy from the level of the first-third costo-vertebral angle, without intraoperative complications. Following surgery, acute paraplegia was diagnosed, with a spinal cord lesion at the high thoracic level. Magnetic resonance imaging did not reveal any disorder in the spinal cord. In response to medical treatment, the patient's locomotor and sensation functions normalised within six months. On revising the preoperative computed tomography, we found dilated vessels passing through the tumour and the hypoplastic vertebral artery on the left side. This finding led us to suspect that the spinal cord circulation was partially supplied by the arteries passing through the tumour, which were clipped during surgery. Verification of the blood supply of the spinal cord is therefore highly recommended before resection of a giant tumour from the posterior mediastinum.

Reoperative Coronary Artery Bypass Grafting via Left Thoracotomy and Hypothermic Fibrillation

Left posterolateral thoracotomy approach for reoperative coronary artery bypass grafting (CABG) is a useful alternative to median sternotomy. We describe use of a left posterolateral thoracotomy and hypothermic fibrillation for reoperative CABG in a patient with patent bilateral internal thoracic artery grafts.

Extrapleural hematoma as a complication following thoracotomy for pulmonary lobectomy

Extrapleural hematoma as a complication following thoracic surgery is rare. We report a case of an extrapleural hematoma following pleural lobectomy that resolved completely with nonsurgical treatment. A 63-year-old woman underwent left lower lobectomy for lung cancer through a left posterolateral thoracotomy. She had been prescribed the anticoagulant cilostazol to increase her heart rate for atrioventricular dissociation. Preoperatively, it was stopped, and a temporary pacemaker was placed to counteract bradycardia via the right jugular vein without complication. The chest tube was removed, and cilostazol was resumed on the third postoperative day. On day 7, she suddenly experienced left shoulder pain followed by hypotension, tachycardia, and anemia. Enhanced computed tomography (CT) revealed an extrapleural hematoma rather than a hemothorax. She became symptomatic after rapid infusion. The hematoma resolved without an invasive intervention. The CT results 189 days after the onset showed almost complete regression of the hematoma.

Pericardial tamponade after left posterolateral thoracotomy for left upper lobectomy for pulmonary aspergilloma

Pericardial tamponade limits diastolic filling of the heart; therefore, a high venous pressure is required to fill the ventricle. In presence of cardiac tamponade, therapeutic agents and manoeuvres that results in venodilation or vasodilation can severely compromise diastolic filling of the heart and might result in rapid cardiac decompensation. Equalization of central venous pressure and pulmonary artery diastolic pressure or equalization of pressures in all four chambers during diastole confirms cardiac tamponade. Transthoracic echocardiography can detect the site of tamponade and assist in pericardiocentesis. We describe acute pericardial tamponade in a young man who underwent left posterolateral thoracotomy for left upper lobectomy. Intraoperatively, mobilization of the left upper lobe was frequently associated with hypotension. Postoperatively, the patient suffered two more episodes of hypotension. The episodes of hypotension were attributed to surgical manipulation and epidural blockade. Hemodynamics normalized after discontinuing epidural infusion, volume resuscitation and lobectomy. On third postoperative day, the patient developed cardiovascular collapse; arterial blood pressure and central venous pressure were 70/50 and 12 mmHg. Investigations showed haziness of left lung, and severe respiratory acidosis. On opening of the left thoracotomy wound, pericardial tamponade was diagnosed. A pericardial window was created and tamponade was released with that the hemodynamics normalized. Episodes of unexplained hypotension after left upper lobectomy suggest a cardiac etiology and acute pericardial tamponade is a possibility which should be released immediately otherwise it can result in fatal outcome.

Huge Aortic Aneurysm After Balloon Angioplasty for Coarctation of the Aorta in an Infant

A 11-month-old boy was referred to our unit for operation. When he was 20 days old, he had balloon dilatation of the aortic coarctation at another institution. He also had a small ventricular septal defect. During the follow-up, asymptomatic aneurysm formation at the previous coarctation site was determined. On physical examination, there was a systolic mummur at the 4th intercostal space. The echocardiographic examination revealed a small perimembraneous-outlet ventricular septal defect and the aneurysm at the coartation site. Cardiac angiography revealed the giant aneurysm of the descending aorta that was 4.4 cm in diameter (Fig. 1; Clip 1). The surgical approach was made though a left posterolateral thoracotomy. At surgery, the aneurysm (Fig. 2) was incised longitudinally (Fig. 3) and both lateral walls and the anterior wall of the aorta that was involved in the aneurysm were resected. The remainder posterior wall was intact and was not integrated in the aneurysm tissue. Patch aortoplasty was performed with a Hemashield patch (Boston Scientific, Natick, MA). The patch was sutured to the aorta in the standard fashion using a running 5/0 prolene suture (Fig. 4). The postoperative course was uneventful. The patient was discharged on the fourth postoperative day. The patient was well at the 25-month follow-up.

Thoraco-abdominal aortic conventional surgery in elderly population

BackgroundThoraco-abdominal aortic pathologies are universallyconsidered as lethal conditions. The most prevalentetiology is atherosclerotic or degenerative but otheretiologies such as mycotic, post-traumatic, connectivetissue disease-related and dissection-related are alsoencountered. The estimated actuarial 1-year and 5-yearsurvival rates in patients with thoraco-abdominal aorticaneurysm is 60% and 20% respectively in untreatedpatients [1,2]. The prognosis, with or without treatment,is complicated by high incidence of comorbidities and isstrictly related with a predominantly elderly population.Since the early ’90s many Authors have investigated theefficacy of endovascular treatment in the treatment ofthoracic and thoraco-abdominal aortic aneurysms and/or complicated aortic dissections. On this basis webelieve that conventional surgery may be reserved alsoin patients over 70 years-old in absence of severepreoperative comorbidities such as chronic obstructivepulmonary disease, renal insufficiency, coronary arterydisease, cerebral vasculopathy.Our surgical approach involves graft replacementbetween the distal aortic arch and the descending thor-acic aorta through a left posterolateral thoracotomy pre-paring proximal and distal aortic cuffs using biologicalglues and external strips of Teflon felt to reinforce thewall. Moreover cerebrospinal fluid drainage by acatheter inserted at the level of L3 or L4 to maintain apressure of 10 mmHg or below and perfusion of thedistal aorta using femoro-femoral bypass is performed.All patients are positioned on the operating table in thelateral position with the abdomen and the pelvis turnedso that the groin was at a 45 angle to the table to allowcannulation of the femoral vessels.In a preliminary study comparing endovascular andconventional surgery treatments in patients with acutetype B aortic dissection, the early results regarding hos-pital mortality and postoperative complications are infavour of endovascular management but no significantdifferences are found in terms of survival at 1, 3 and8 years.ConclusionsConventional surgery in the treatment of thoracic andthoraco-abdominal aortic pathologies also in elderlypopulation may be considered an effective procedure inthe era of stent graft. The aim of further randomizedstudies study is to demonstrate the real superiority ofendovascular procedure over open surgery and to defineits role in the treatment of aortic pathologies especiallyin terms of mid and long-term follow-up.

Repeated Successful Thrombolysis of a Jarvik 2000 Left Ventricular Assist Device in a Patient With Noncompaction Cardiomyopathy

28-year-old white man with history of end-stage heart failure caused by isolated left ventricular (LV) noncompaction cardiomyopathy had been implanted with the Jarvik 2000 LV assist device 3 years previously as a bridge to survival and to decision via a left posterolateral thoracotomy, off-pump, with outflow graft anastomosis to the descending aorta and postauricular pedestal. The patient had an excellent postoperative course free of adverse events for 1.5 years. The pump was operated at a rotational speed of 9000 rounds per minute. Anticoagulation included acenocoumarol aiming for an international normalized ratio of 3 to 3.5 and 100 mg of aspirin daily. On the 20th month of support, the patient presented with symptoms and signs of cardiogenic shock associated with a sudden increase in power consumption by the …

Incidental detection of a giant ductus arteriosus aneurysm by low-dose multidetector computed tomography in an asymptomatic adult

Aneurysm of the ductus arteriosus is a very rare congenital lesion in adults that can be associated with thromboembolism, rupture, and death. Its detection in a silent clinical phase is very important for planning appropriate treatment and avoiding potentially fatal complications. We report a case of a patent ductus arteriosus aneurysm of very large size (65.5 mm) that was incidentally discovered with low-dose (3.2 mSv) multidetector computed tomography in an asymptomatic 67-year-old man. The presence of coronary disease was also ruled out with this non-invasive imaging modality. Further evaluation with echocardiography and selective angiography confirmed the diagnosis. At surgery, the aneurysm was successfully resected via a left posterolateral thoracotomy.

Combined esophagogastric resection for cancer at esophagogastric junction and off pump CABG through left posterolateral thoracotomy

Carcinoma of the esophagus can coexist with significant Coronary Artery Disease (CAD) in the elderly. A staged approach to the two problems, carrying out Coronary Artery Bypass Grafting (CABG) first followed by cancer resection at two anesthetic settings is a logical way of tackling the conditions. But it lengthens morbidity and increases economic burden. Simultaneous tackling of these two problems, i.e. operation at the same anesthetic settings can offer a better outcome albeit at the cost of a longer operative time. We present such a patient who underwent simultaneous Off Pump Coronary Artery Bypass Grafting (OPCAB) and esophago-gastric resection successfully through a posterolateral thoracotomy and upper midline laparotomy.

Accessory Liver Lobe in the Left Thoracic Cavity

Accessory liver of the thoracic cavity is usually asymptomatic, and its incidental detection is extremely rare. In this study, an unusual case of an accessory liver lobe of the thoracic cavity in a 26-year-old woman is described. A chest roentgenogram and thoracic computed tomographic scan revealed a mass in the left thoracic cavity. Left posterolateral thoracotomy was performed by removing a 10 x 8 x 5 cm(3) mass separated from lung. The arterial and venous supply of the mass originated from the abdomen. The diaphragm was found to be intact. The pathologist reported a normal hepatic tissue. This report presented a very rare occurrence of accessory liver in the thoracic cavity.

Divertículos epifrénicos: ¿cuándo y cómo operar?

The majority of epiphrenic diverticula arise due to a peristaltic mechanism caused by an oesophageal motor disturbance that establishes a barrier effect and causes mucosal and submucosal herniation through a weak point in the muscular layer. Intraluminal oesophageal manometry and video-radiology are important in assessing these patients, since they define the characteristics of the functional disorder, as well as the true relationship between the symptoms of the patient and the diverticulum. Surgical treatment is indicated in symptomatic patients, more so if there are respiratory complications. Left posterolateral thoracotomy followed by diverticulotomy, oesophageal cardiomyotomy and anti-reflux have been considered the surgery technique of choice. Oesophageal myotomy must go beyond, in a proximal direction, the neck of the diverticulum, and, in a distal direction, must progress 1–2 cm into the gastric wall. The laparoscopic approach has won many followers since it has been shown to be both safe and effective as open surgery, adding to the advantages of minimally invasive surgery.

Extended replacement of aortic arch aneurysms through left posterolateral thoracotomy

To present our experience of total aortic arch replacement through a left posterolateral thoracotomy. Sixteen patients (13 males; mean age 62.1+/-11.3 years) with extended thoracic aortic aneurysms, including those in the thoracoabdominal aorta, underwent replacement through a left posterolateral thoracotomy. The pathology of the diseased aorta was non-dissecting aneurysm due to aortitis in 1 patient and aortic dissection in 15 patients (acute type A: 1, chronic type A: 12, chronic type B: 2). In a prior operation, the patient with aortitis had undergone the Bentall procedure with endovascular stenting of the brachiocephalic artery, and among the other 15 patients, one previously had endovascular stenting for the aortic arch and 12 had hemi-arch replacement for acute type A dissection. Extension of arch replacement was the aortic arch and descending aorta in eight patients, the ascending arch and descending aorta in five patients and the descending arch, and thoracoabdominal aorta in three patients. Additional retroperitoneal dissection was required for the repair of a thoracoabdominal aortic aneurysm. One patient died of traumatic cerebral hemorrhage on day 145 (hospital mortality 6.3%). Average duration of ventilation support was 19.4+/-17.0h and length of ICU stay was 3.6+/-1.6 days. Actuarial survival at 2 years after the operations was 67.7%. However, no aortic-related mortality was observed during follow-up. Early results of extended aortic arch replacement through a left posterolateral thoracotomy were satisfactory in selected patients.

Extraskeletal Ewing's Sarcoma/Primitive Neuroectodermal Tumor of the Posterior Mediastinum with t(11;22)(q24;q12)

Ewing's sarcoma/primitive neuroectodermal tumor family of tumors is part of a rare group of malignant neoplasms with small round-cell morphology. We describe a 24-year-old woman who presented with non-specific back pain. A chest radiograph and magnetic resonance imaging demonstrated an extraosseous, dumbbell-shaped mass of the posterior mediastinum with extension into the spinal canal. The patient underwent a left posterolateral thoracotomy and a T3-5 laminectomy with subsequent multi-agent chemotherapy. Histopathologic examination of the tumor demonstrated sheets of primitive small round malignant cells that showed no visible differentiation. Neoplastic cells were strongly immunoreactive for CD99 and vimentin and were negative for chromogranin, synaptophysin, CD31, CD34, calcitonin, desmin, low-molecular weight cytokeratins, wide-spectrum cytokeratins, leukocyte common antigen, S-100 protein, and thyroid transcription factor-1. The neoplasm was diagnosed as a Ewing's sarcoma/primitive neuroectodermal tumor, and cytogenetic studies confirmed a t(11;22)(q24;q12) chromosomal translocation and an associated trisomy of chromosome 2, supporting the histologic diagnosis. Extraskeletal Ewing's sarcoma/primitive neuroectodermal tumors are rare neoplasms that should be distinguished from other small round-cell tumors by morphology and ancillary laboratory techniques. Although rare, they need to be considered in the differential diagnosis of primary mediastinal tumors.

Displacement of Double Lumen Tube After the Rupture of a Giant Lung Bulla During Bullectomy

To the Editor: Malpositioning of a double lumen tube (DLT) can occur during airway management for intrathoracic procedures.1 We encountered an unusual cause of right sided DLT displacement in a 23-yr-old patient scheduled for elective left side bullectomy. Computed tomography scan of the chest (Figure 1) revealed a giant bulla occupying left apical, lingular, and part of the lower lobe with significant mediastinal shift towards the right. After induction of anesthesia and tracheal intubation, the patient was positioned for left postero-lateral thoracotomy with two-lung ventilation initially. During dissection, the bulla was suddenly punctured and deflated. The relief from compressive effects of the bulla did not improve lung mechanics. There was no lung expansion on left side and a paradoxical increase in peak airway pressure, followed by arterial hemoglobin desaturation, increased end tidal carbon dioxide, and an absence of breath sounds over right apical region. Fiberoptic bronchoscopy revealed a distally displaced DLT in the right bronchus (Figure 2). Withdrawing the tube gradually restored audible breath sound on the right apical region and completely resolved the problem. We conclude that, following rupture of the bulla, a leftward carinal shift over a relatively fixed DLT led to placement of the DLT more distally inside the right bronchus.Figure 1.: CT Chest showing a giant bulla with tracheal shift.Figure 2.: Schematic illustration of carinal shift over relatively fixed of DLT.In conclusion, while identifying the causes of arterial desaturation during DLT ventilation, the possibility of a misplaced DLT due to intraoperative carinal shift after rupture of a giant bulla must also be considered. Deepak Thapa, DA, DNB Lakshmi Mahajan, MD Lalit Gupat, DA Department of Anaesthesia and Intensive Care Government Medical College and Hospital Chandigarh, India [email protected]

Modificação técnica para correção de coarctação aórtica com hipoplasia do arco aórtico

To study technical feasibility and early results of the technical modification suggested by Caliani et al. for correction of aortic coarctation and aortic arc. Between January 2005 and July 2006, nine newborn patients with aortic coarctation and significant aortic hypoplasia were selected, and underwent a new surgical approach in order to correct this aortic defect. The definition of aortic arch hypoplasia according to Moulaert's criteria is an aortic arch with a diameter that is less than 50% of the diameter of the ascending aorta. In this study, only patients with proximal and distal aortic hypoplasia were selected. Many techniques were previously used, but significant residual gradients were observed, as well as the incovenience of definitive occlusion of the left subclavian artery. The aim of this study is to describe a new surgical technique that includes left posterolateral thoracotomy, wide mobilization of descending aorta with occlusion of the first two intercostal branches, transection of the left subclavian artery at its base, wide resection of the hypoplastic area and the surrounding regions of the ductus arteriosus; end-to-end anastomosis between the aortic arch and descending aorta, with 7-0 PDS thread and reimplantation of the subclavian artery into the left carotid artery with side-to-end anastomosis. There were no perioperative or late deaths. The mean residual gradient was 5 mmHg. Up to now, there were no cases of recoarctation or medullary neurological lesions. Despite the small number of cases and the short follow-up, this technique modification may be an excellent option for the treatment of this complex situation.