Axillary Line Research Articles

A Simple and Reliable 2D-Shear Wave Elastography and UltraSound Coefficient Attenuation Parameter Technique in Chronic Liver Diseases.

The performance and reliability criteria for Aixplorer MACH30 (SS) in chronic liver diseases (CLD) have not been validated. The objectives were to define the optimal procedure, the accuracy for fibrosis and steatosis diagnosis, and the reliability criteria using SS. Patients had 2D-shear wave elastography (SWE) and ultraSound-guided controlled attenuation parameter (SCAP) performed in triplicate at the mid-axillary line (MAL), posterior axillary line (PAL), and anterior axillary line (AAL). Performances of SWE and SCAP were defined using transient elastography (TE ≥ 9.5kPa) and CAP (≥ 275dB/m) using Fibroscan (FS) as reference and validated with liver biopsy (LB). FS and SS data from 203 CLD patients were analyzed (55 ± 14years; 59% male; MASLD 58%). Median TE and CAP were 6.4kPa (2.5-66.9) and 270dB/m (141-400). The best technique for the diagnosis of advanced fibrosis and significant steatosis was the median of three SWE values and three SCAP values at MAL, PAL, and AAL with an AUROC of 0.96 [95% CI 0.93-0.98] and 0.91 [95% CI 0.86-0.95]. Only skin-to-liver distance ≥ 2.4cm (p = 0.012, 95% CI 1.37-13.38) was independently associated with discordance. The accuracy of SWE (≥ 8.5kPa) and SCAP (≥ 0.44) was analyzed in 58 patients with LB. The PPV and NPV were 50% and 94%, and 71% and 88% for fibrosis and steatosis, respectively. A reliable diagnosis of advanced fibrosis and significant steatosis can be obtained with the median of three measurements in different liver portions using SS. The only non-reliable criterion is skin-to-liver distance ≥ 2.4cm.

Direct Subscarpal Lipectomy Combined With Liposuction in Abdominoplasty: An Analysis of Safety and Efficacy in 200 Consecutive Patients.

Abdominoplasty procedures continue to evolve because combining techniques such as suction-assisted lipectomy or direct subscarpal lipectomy have proven to be powerful adjuncts to achieve optimal aesthetic results. However, concern has been expressed about combining techniques simultaneously given the potential to damage the vascularity of the abdominoplasty flap. The aim of this study was to assess the safety and efficacy of simultaneous direct subscarpal lipectomy combined with liposuction in abdominoplasty patients. A 4-year retrospective review of consecutive abdominoplasties (n = 200) performed by a single surgeon was conducted. Liposuction of the abdominal flap and flanks was performed in all patients. After raising the abdominoplasty flap, undermining was performed to just beyond the xyphoid, the lower rib margins superiorly, and the anterior axillary line laterally. Fat deep to Scarpa's fascia was then removed by direct tangential excision in all zones of the abdominal flap. The patients had a mean age of 42.19 years and BMI of 28.10 kg/m2; the mean follow-up time was 7 months. Seroma occurred in 13 patients (6.5%), superficial wound dehiscence treated with local wound care in 16 patients (8%), hypertrophic scarring in 16 patients (8%), partial umbilical necrosis in 1 patient (0.5%), and partial umbilical epidermolysis in 6 patients (3%). No patients experienced major or minor full-thickness tissue loss. No patients needed reoperation. Simultaneous direct excision of subscarpal fat with liposuction of the abdomen and flanks does not appear to subject any zone of the abdominoplasty flap to increased risks of vascular compromise. No flap necroses were observed. The technique described is safe and may provide superior abdominoplasty results.

Case Report: Post-operative mitral valve replacement complicating with a large cardiac mass and role of TEE in decision making

Background Postoperative complications are an integral part of valve surgery. Common complications include hematomas, bleeding, valve dehiscence, paravalvular leak, and acute PV thrombosis. With the available data from published articles, the rate of all valve-related complications is 0.7 to 3.5% per patient annually. [1] The pathology involved is multifactorial, often blood vessel injury leading to bleeding and hematoma. Although postoperative complications are evident, incidental diagnosis of a cardiac mass in an asymptomatic and hemodynamically stable patient postoperatively is crucial, requiring non-invasive imaging for immediate surgical action. Case presentation A woman in her 50s presented with chief complaints of worsening dyspnoea with suddenonset and chest pain. Clinical findings showed apex shifted downward and outward, wide split S2, and a mid systolic murmur radiating to the mid axillary line. Twelve-lead ECG showed LA enlargement, that aligned with X-ray findings. 2D Echocardiography revealed MVP with severe MR and a dilated LV. The patient underwent successful mitral valve replacement as per ACC/AHA class I recommendation. However, postoperative TTE showed a remarkably large mass measuring 5.6 cm*4.6 cm in the RA. Reexploration was performed, followed by mass excision. Plenty of organized clots were seen compressing the RA. TEE showed no evidence of mass. Following stabilization,the patient was discharged considering optimal INR values and prosthetic valve function assessed by echocardiography. The patient’s symptoms improved during the first follow-up. Conclusion Although postoperative cardiac complications are common, appropriate diagnosis with TTE and TEE has benefited surgeons. TEE-guided reexploration aids surgeons in decision-making and strategic approaches. Failure to diagnose such complications in asymptomatic patients can ultimately complicate the procedure. Henceforth, sonographers must be skilled in the detection and identification of unusual complications to guide redo interventions. Such an approach minimizes mortality, redo procedures, and avoids CPB hence reducing long-term prognosis and outcomes with valve replacement.

Radiologic assessment of the optimal point for tube thoracostomy using the sternum as a landmark: a computed tomography-based analysis.

This study aimed at developing a novel tube thoracostomy technique using the sternum, a fixed anatomical structure, as an indicator to reduce the possibility of incorrect chest tube positioning and complications in patients with chest trauma. This retrospective study analyzed the data of 184 patients with chest trauma who were aged ≥18 years, visited a single regional trauma center in Korea between April and June 2022, and underwent chest computed tomography (CT) with their arms down. The conventional gold standard, 5th intercostal space (ICS) method, was compared to the lower 1/2, 1/3, and 1/4 of the sternum method by analyzing CT images. When virtual tube thoracostomy routes were drawn at the mid-axillary line at the 5th ICS level, 150 patients (81.5%) on the right side and 179 patients (97.3%) on the left did not pass the diaphragm. However, at the lower 1/2 of the sternum level, 171 patients (92.9%, P<0.001) on the right and 182 patients (98.9%, P= 0.250) on the left did not pass the diaphragm. At the 5th ICS level, 129 patients (70.1%) on the right and 156 patients (84.8%) on the left were located in the safety zone and did not pass the diaphragm. Alternatively, at the lower 1/2, 1/3, and 1/4 of the sternum level, 139 (75.5%, P=0.185), 49 (26.6%, P<0.001), and 10 (5.4%, P<0.001), respectively, on the right, and 146 (79.3%, P=0.041), 69 (37.5%, P<0.001), and 16 (8.7%, P<0.001) on the left were located in the safety zone and did not pass the diaphragm. Compared to the conventional 5th ICS method, the sternum 1/2 method had a safety zone prediction sensitivity of 90.0% to 90.7%, and 97.3% to 100% sensitivity for not passing the diaphragm. Using the sternum length as a tube thoracostomy indicator might be feasible.

Visual lung ultrasound protocol (VLUP) in acute respiratory failure: description and application in clinical cases

Lung ultrasound (LUS) is widely used as a diagnostic and monitoring tool in critically ill patients. Lung ultrasound score (LUSS) based on the examination of twelve thoracic regions has been extensively validated for pulmonary assessment. However, it has revealed significant limitations: when applied to heterogeneous lung diseases with intermediate LUSS pattern (LUSS 1 and 2), for instance, intra-observer consistency is relatively low. In addition, LUSS is time-consuming and a more rapid overview of the extent of lung pathology and residual lung aeration is often required, especially in emergency setting. We propose a Visual Lung Ultrasound Protocol (VLUP) as a rapid monitoring tool for patients with acute respiratory failure. It consists of a probe sliding along the mid-clavicular, mid-axillary and scapular lines in transversal scan. VLUP allows a visualization of a large portion of the antero-lateral and/or posterior pleural surface. Serial assessments of two clinical cases are recorded and visually compared, enabling rapid understanding of lung damage and its evolution over time. VLUP allows a semi-quantitative and qualitative point-of-care assessment of lung injury. Through this standardized approach it is possible to accurately compare subsequent scans and to monitor the evolution of regional parenchymal damage. VLUP enables a quick estimation of the quantitative-LUSS (qLUSS) as the percentage of pleura occupied by artifacts, more suitable than LUSS in inhomogeneous diseases. VLUP is designed as a standardized, point-of-care lung aeration assessment and monitoring tool. The purpose of the paper is to illustrate this new technique and to describe its applications.

A Retrospective Analysis of Needle Thoracostomies at a Tertiary Level 2 Trauma Center.

A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily. A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population. The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression. Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.

Diaphragm atrophy during invasive mechanical ventilation is related to extubation failure in preterm infants: An ultrasound study.

Diaphragm dysfunction is associated with poor outcomes in critically ill patients. Ventilator-induced diaphragmatic dysfunction (VIDD), including diaphragm atrophy (DA), is poorly studied in newborns. We aimed to assess VIDD and its associations in newborns. Single-center prospective study. Diaphragm thickness was measured at end-inspiration (TDI) and end-expiration (TDE) on the right midaxillary line. DA was defined as decrease in TDE ≥ 10%. Daily measurements were recorded in preterm newborns on invasive mechanical ventilation (IMV) for ≥2 days. Clinical characteristics of patients and extubation failure were recorded. Univariate analysis, logistic regression, and mixed models were performed to describe VIDD and associated factors. We studied 17 patients (median gestational age 270/7 weeks) and 22 IMV cycles (median duration 9 days). Median TDE decreased from 0.118 cm (interquartile range [IQR]0.094-0.165) on the first IMV day to 0.104 cm (IQR 0.083-0.120) on the last IMV day (p = .092). DA occurred in 11 IMV cycles (50%) from 10 infants early during IMV (median: second IMV day). Mean airway pressure (MAP) and lung ultrasound score (LUS) on the first IMV day were significantly higher in patients who developed DA. DA was more frequent in patients with extubation failure than in those with extubation success within 7 days (83.3 vs. 33.3%, p = .038). DA, significantly associated with extubation failure, occurred in 58.8% of the study infants on IMV. Higher MAP and LUS at IMV start were associated with DA. Our results suggest a potential role of diaphragm ultrasound to assess DA and predict extubation failure in clinical practice.

Association of Diaphragmatic Thickness and Peripheral Muscle Thickness using Ultrasonography in Extubation Outcome

Introduction Patients in icu who are critically sick require basic life support in form of mechanical ventilator. Ventilator associated complication are common in them . Prediction of icu acquired weakness can prevent extubation failure, decrease in hospital mortality and increase icu free day. Thereby decreasing financial burden . Both central and peripheral muscle thickness play role in predicting extubation success. Aim/Objective :Aim is to measure muscle strength of diaphragm and quadriceps muscle using ultrasonography and to find if central and peripheral muscle strength can be used as a predictor for patients’ extubation outcome. Study design : Prospective crossectional single centred observational study . Place and duration of the study : The study was carried out in PCCM department of Kgmu from January 2023 to October 2023. Methodology: Diaphragm excursion , diaphragm thickness at inspiration and expiration was measured using ultrasonography on right side at 8 th and 9th intercostal space between anterior and mid axillary lines. Quadriceps thickness was also measured at mid point between the anterior superior Iliac spine to patella and was compared with the outcome of the intubated patient . Results : Out of 42 patients 52% were male(n=22) and 48% were female (n=20). The study showed that the diaphragmatic excursion ( p value &lt;0.001 ) and diaphragmatic thickness at inspiration (p value 0.007 ) was significant in predicting outcome of the patient from mechanical ventilator but quadriceps thickness had no significance( pvalue 0.012). The excursion of the patient &lt;7 , 7-11 and &gt;11 has extubation success of .0%, 46.2 % and 53.8 % respectively. The diaphragmatic inspiration thickness of &lt;1.65 , 1.65 - 3.7 &gt;3.7 has successfull weaning of 0% , 100% and 0% respectively. Conclusion: Diaphragm excursion plays strong role in predicting the success of extubation and preventing icu acquired weakness. The study reflect the role of diaphragmatic thickness in better outcomes. Quadriceps muscle couldn't be related much with weaning and extubation.

Ten years of subcutaneous defibrillator therapy: Consolidated clinical evidence and future perspectives.

The subcutaneous implantable cardioverter defibrillator (S-ICD) was developed as an alternative to the traditional transvenous implantable cardioverter defibrillator (TV-ICD), aiming to provide easier implantation, simplified detection algorithm of malignant ventricular arrhythmias and prevention from placing components in the cardiovascular system. The S-ICD is implanted subcutaneously or intramuscularly with the generator placed in the left midaxillary line and the lead tunneled subcutaneously in the left para-sternal region. Preimplant electrocardiogram screening is recommended to prevent implantation in patients at high risk of T wave over-sensing. Currently, the S-ICD is unsuitable for patients requiring pacing or cardiac resynchronization. Since the beginning, the S-ICD underwent extensive preclinical investigation until the first prospective multicentre trial demonstrating high efficacy and safety led to market release. While earlier studies focused on younger patients with higher ejection fraction, more recent studies showed favorable outcomes even in patients with comorbidities similar to those typically observed in patients receiving TV-ICD. The development of second and third generation devices has contributed to reduce inappropriate shocks and overcome previous limitations. The aim of this paper is to review the evidence in the literature over the past decade supporting S-ICD as a valid alternative to TV-ICD in terms of safety and efficacy, highlighting the improvements in technology, as well as outcomes.

Single port endoscopic thoracic sympathectomy with holmium laser for treating palmar hyperhidrosis at Thai Binh Provincial General Hospital

Introduction: thoracoscopic sympathectomy for treating palmar hyperhidrosis often uses 2 ports. Research to evaluate the results of the method using 1 port &lt; 5mm with Holmium Laser fiber.&#x0D; Object and Method: Description, prospective.&#x0D; Within 2 months from June 2023 to July 2023, 47 patients underwent single port endoscopic thoracic surgery using holmium laser to transect the sympathetic ganglia at T3 level for patients with palm sweating (26 patients) and T3-T4 level for patients with palm and axillary sweating (21 patients). The male-to-female ratio was 44.7% to 55.3%, with an average age of 18 ± 7.4 years (minimum age of 11 years, maximum age of 52 years). Surgical method: A single entry port trocar 14Fr located at the 3rd intercostal space, the posterior border of the pectoralis major muscle between the anterior and midaxillary lines, using a 12Fr endoscopic lens with integrated tunnel for Holmium Laser fiber. Patients were monitored and evaluated for early post-operative results: technical failure requiring the placement of a second port, complications during and after surgery and the degree of improvement in palmar hyperhidrosis, the rate of compensatory hyperhidrosis after 1 month and the patient's quality of life after surgery.&#x0D; Results:&#x0D; There were no technical failures. The time for transecting the sympathetic ganglion (one side) with Holmium Laser was 78 ± 40.76 seconds. All patients had dry hands after surgery, with two out of forty-seven patients having excessively dry hands. There were no complications during or after surgery, and no patients developed Horner’s syndrome. The average time to discharge after surgery was 30 ± 11.4 hours. Fourteen out of forty-seven patients had compensatory sweating after one month postoperatively at an acceptable level.&#x0D; Conclusion: The method of using a port &lt; 5mm with an endoscopic lens integrated with a Holmium Laser fiber tunnel is safe, effective, less traumatic and highly aesthetic.

New Insights Into Breast and Chest Wall Asymmetry in the Aesthetic Patient

Abstract Background Asymmetry, a prevalent phenomenon throughout the human body, prompts this retrospective study, in which the authors aim at discerning potential patterns in its manifestation. Building upon our previous investigations in which left-sided chest wall and pelvic bone width surpassed their right-sided counterparts, a hypothesis is formulated suggesting the likelihood of the right breast being narrower and longer compared with the left. Objectives Our objective in this study is to investigate the correlation between the left-sidedness phenomenon in the chest wall and breast shape and appearance, with the aim of understanding its potential impact on outcomes in breast aesthetic surgery. Methods A random selection of pictures from 600 female patients undergoing various aesthetic breast procedures formed the basis of this study. Exclusion criteria involved the elimination of 254 pictures with nonstandard photography. Horizontal and vertical parameters of breasts and chest walls were measured, and the results on both sides were systematically compared to validate our hypothesis. Results On the left side, the chest wall, the distance between the nipple and the midline, and that of the nipple and the anterior axillary line were significantly wider. Vertical measurements, including the sternal notch to the nipple, the clavicle to the nipple, and the clavicle to inferior breast distance, although longer, did not exhibit statistical significance. Conclusions Approximately 77% of patients displayed wider breasts and chest walls on the left side. However, this observed asymmetry did not yield a statistically significant impact on the length of the breasts. Level of Evidence: 3 (Diagnostic)

Management of Extensive Subcutaneous Emphysema with Blow Hole Infraclavicular Incision and Continuous Suction Installation

Background: Subcutaneous emphysema often occurs in cases of implanted pneumothorax chest tubes and must always be evaluated. Subcutaneous emphysema is a condition where air or gas is found in the tissue under the skin.&#x0D; Case presentation: A 49-year-old man was treated for sudden shortness of breath that occurred after a violent cough accompanied by pain and heaviness in the chest area 1 day before admission to the hospital. The patient had previously received anti-tuberculosis drug treatment for 6 months based on chest X-ray results in 2022, and the patient had undergone a rapid molecular test (TCM) examination, mycobacterium tuberculosis (Mtb), and obtained Mtb results not detected. Lung auscultation obtains sound intensity breath weakness until it disappears in both lung fields. Palpation of the skin revealed widespread crepitus on the face, neck, upper extremities, back, chest, and abdomen. The range of motion areas of the neck, shoulders, and hands are limited due to pain with movement. Evaluation of the chest tube obtained: the chest tube was installed in the anterior axillary line on the right at the level of the 5th intercostal space with number 10 attached to the chest wall and the chest tube well fixed to the chest wall. The end chest tube has been connected to the WSD bottle, and evaluation of the WSD shows that there are undulations and bubbles.&#x0D; Conclusion: The patient was admitted with spontaneous pneumothorax secondary to tuberculosis and was implanted with a chest tube.

Rhomboid intercostal sub serratus plane block – Same bird with different horizons

Sir,We did a case series in five patients undergoing modified radical mastectomy who were given RISS for post-operative analgesia. We noticed that the intraoperative fentanyl consumption as well as the post-operative analgesic consumption was significantly less. The overall quality of life and satisfaction score for routine daily activities like wearing clothes was better in our patients. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. These planes have various cutaneous as well as sympathetic branches and hence drug given spreads to cover a large dermatomal area. RISS has been proposed to cover lateral cutaneous branches of T2 to T11 that extend medially to cover dorsal rami deep to the errector spinae muscle plane (ESP). The site of injectate is at T5-T6. The dermatomal coverage is 4 cm lateral to the midline anteriorly, posteriorly 4 cm medial to the posterior axillary line, cranially up to serrated posterior superior caudally up to serratus posterior inferior. The advantages of RISS block are that the injection is far from the surgical site and hence the drug does not interfere with the surgical field or cautery if given preoperatively. After induction technically, it is more feasible than serratus plane block or pectoral blocks. Logistically prior catheterization is possible that does not interfere with the sterility of the surgical field. Despite the above advantages, the axillary coverage is inconsistent as it does not cover the intercostobrachial nerve (LCB of second ICN T2). The midline, thoracodorsal nerve, and long thoracic nerve are not covered. Complete analgesia is not provided for latissimus dorsi flap, segmental resection surgeries, lymph node dissections, or radical mastectomies. Dr. Tulgar, first-ever reported of the use of RIB in a patient of MRM and highlighted the superiority of peri-peri-paravertebral blocks apart from previously used ESP and paravertebral blocks for a similar condition. Altiparimak conducted an RCT on 30 MRM patients with axillary lymph node dissection. The patients had enhanced recovery and quality of life scores (QoR-40), especially in terms of pain and emotional status. RISS has proved its non-inferiority as compared to ESP, paravertebral, PEC, and SAP which are closer to neuroaxis, at non-compressible sites and difficult to execute in obese patients. Thus RISS is excellent as a part of MMA for post-operative pain management in MRM patients, who remain comfortable for up to 14 h and have an NRS score &lt;3 was seen in all of our five patients. The dynamic nature of pain was apparent at 14 h in three of the patients who had extensive axillary lymph node dissection. Is the journey of regional anesthesia just the replacement of “pops and clicks” with see it and block it? The renaissance in the era of blocks is visualizing an invention of a new block almost every month. We depend on the facial plane anatomy, its structure, and its relation to the surrounding organs and tissues to precisely disseminate the local anesthetic to its desired location. In this blind sheep race, enthusiasm should not blur our understanding of the basics. We should remember Triple A, improve health, enhance patient outcomes, and decrease the costs. We open the doors for larger studies with more patients, comparing different blocks with RIB/RISS blocks before generalizing the results. CONCLUSIONRhomboid intercostal subserratus plane block is an excellent option for intra and post-operative pain management as a part of multimodal analgesia in MRM patients.

A Case of Male Breast Cancer and a Literature Review

Background: Breast cancer in men, similar to that in women, originates in the mammary gland epithelium (ducts), and although less common than in women, its incidence has increased in recent decades, accompanied by significant advances in understanding the disease as a distinct entity. It shares important similarities with its female counterpart, with significant progress in diagnosis and treatment. Case presentation: In this report, we describe the clinical and imagenological characteristics of a 64-year-old man with metastatic adenocarcinoma to the skin. The patient presented with an ulcerative lesion on the right hemithorax, along the mid-clavicular line and anterior axillary line at the fifth intercostal space. The lesion had a soft, necrotic appearance, was prone to bleeding, and was referred by the patient as "resulting from trauma" a year ago, with progressive expansion and deepening, despite antibiotic use and cleansing of the wound. It invaded the surrounding skin, which appeared desquamated, erythematous with neovascularization, friable to the touch prone to bleeding with difficulty to achieve hemostasis, and multiple brownish nodular satellite lesions, with no other associated symptoms. A thoracic CT scan performed in the emergency department revealed a bilateral pleural effusion, predominantly on the right side, occupying 50% of the right lung space, along with an osteolytic lesion at the level of the manubrium of the sternum. A follow-up thoracic CT scan showed a pleural effusion occupying 80% of the right lung space, with a minor pneumothorax. The placement of an endopleural chest tube on the right side resulted in the extraction of 1800 ml of serosanguineous fluid, and pleural fluid culture did not reveal microorganisms or tumor cells, making the diagnosis of pulmonary adenocarcinoma less likely. A biopsy of the surrounding tissue yielded an invasive, poorly differentiated adenocarcinoma. Immunohistochemical staining was positive for estrogen and progesterone receptors, CK19, and negative for CK7, CK20, leading to the primary diagnosis of breast cancer based on clinical presentation and lesion location. Conclusions: Breast cancer in men, while sharing similarities with its female counterpart, presents its own unique characteristics. The identification of these factors and education about the significance of this condition, along with the discovery of specific biomarkers and targeted therapies, have the potential to significantly improve the prognosis of male patients in the future.

OGBN P13 Laparoscopic splenectomy for massive splenomegaly: Is it feasible?

Abstract Background Laparoscopy has high credibility in the treatment of normal sized and mildly enlarged spleens. However, there is lack of evidence for its safety for cases with massive splenomegaly. EAES defined massive splenomegaly by maximum splenic diameter exceeding 20 cm. It recommended hand assisted laparoscopic splenectomy (HALS) or open surgery as a treatment for such cases. In this video, we demonstrated the feasibility of the use of laparoscopy in cases with massive splenomegaly with favourable outcomes. Methods We describe a video for a 36 years old female patient who is known Kikuchi syndrome. She had massive splenomegaly which reached 25 cm in its maximum length. Patient was in right lateral position. Camera port was located left to the umbilicus, another 10 mm port at left midclavicular line and two 5 mm ports were used (one at epigastrium and assistant port at left anterior axillary line). The video demonstrates the steps of laparoscopic splenectomy with the challenges of the huge size of the spleen. Specimen was taken through patient’s old caesarean scar (Pfannenstiel incision). Results Patient had CT scan on day 2 for raised inflammatory markers, which showed small collection at splenic bed which was treated conservatively. Patient was discharged on day 5 postoperatively after removal of surgical drain. Clinical review after 4 weeks post discharge didn’t show any clinical concerns. Conclusions Using a stepwise laparoscopic approach is feasible and safe for massive splenomegaly cases. Refining the selection criteria for laparoscopic versus open or HALS splenectomy should be revised with less consideration to the size of spleen as a limiting factor.

Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion.

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed pleural effusions. This single-port procedure is conducted with the patient under mild sedation and involves a contralateral decubitus position. It is performed in a sterile setting, typically a bronchoscopy suite or surgical theater, by a single operator with support from a procedure-focused nurse and a patient-focused nurse. The procedure begins with a thoracic ultrasound to determine the optimal entry point, usually in the IV-V intercostal space along the midaxillary line. Lidocaine/mepivacaine, with or without adrenaline, is used to anesthetize the skin, thoracic wall layers, and parietal pleura. A designated trocar and cannula are inserted through a 10 mm incision, reaching the pleural cavity with gentle rotation. The thoracoscope is introduced through the cannula for systematic inspection of the pleural cavity from the apex to the diaphragm. Biopsies (typically six to ten) of suspicious parietal pleura lesions are obtained for histopathological evaluation and, when necessary, microbiological analysis. Biopsies of the visceral pleura are generally avoided due to the risk of bleeding or air leaks. Talc poudrage may be performed before inserting a chest tube or indwelling pleural catheter through the cannula. The skin incision is sutured, and intrapleural air is removed using a three-compartment or digital chest drainage system. The chest tube is removed once there is no airflow, and the lung has satisfactorily re-expanded. Patients are usually discharged after 2-4 h of observation and followed up on an outpatient basis. Successful LAT relies on careful patient selection, preparation, and management, as well as operator education, to ensure safety and a high diagnostic yield.

Intermuscular placement and defibrillation with the extravascular ICD: a single-centre experience

Abstract Background Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICD), owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. The proposed implantation technique for EV-ICDs is a subcutaneous pocket along the mid axillary line, although an intermuscular ICD placement can potentially reduce the risk of pocket complications, device migration and improve patient comfort and aesthetic outcomes. Purpose exploring the safety and feasibility of extravascular ICDs implantation with a substernal coil and an intermuscular generator placement. Methods Seventeen patients with a class I or IIa ICD indication either for primary (14/17) or secondary (3/17) prevention underwent EV-ICD implantation in our centre as part of the EV ICD Pivotal Study from May 2021 to November 2022. Access and tunnelling along the retrosternal space were performed based on current standard recommendations for EV-ICDs implantation. An intermuscular pocket for generator placement was obtained between the latissimus dorsi and the serratus anterior muscles beyond the left mid-axillary line. Results Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy. The implantation was successful in 16 (6 females) out of 17 patients, with one implant failure due to inadequate sensing (0,5 mV); the median sensing amplitude was 2,3 mV (min = 1,3 mV; max = 5,8 mV), with R1R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16. Defibrillation Testing (DFT) was performed in all patients: a 15 J shock terminated induced ventricular fibrillation (VF) in 12/16 patients, 20 J terminated VF in 3, a single patient had VF terminated at 30 J. No patient had infection or skin erosion or complained pain/discomfort at the pocket site along an 18±4 months follow-up. Only 1/16 patients had ventricular tachycardia at follow-up, successfully treated by the device. Conclusions Intermuscular placement of the EV ICD may be a feasible and reliable alternative to a subcutaneous one in terms of defibrillation efficacy, enabling patient comfort and aesthetic acceptance in thin-habit or young patients. Additional long-term data and larger patient cohorts are required to confirm its advantage compared to the subcutaneous placement.

Validation of a novel point-of-care ultrasound method to assess diaphragmatic excursion

IntroductionPoint-of-care ultrasound can assess diaphragmatic function and rule in or rule out paresis of the diaphragm. While this is a useful bedside tool, established methods have significant limitations. This study...

The Two Facing Square Flaps Method for Release of Anterior and Posterior Axillary Line Burn Contractures

With improved burn outcomes and survival rates, the focus of management in large burns has shifted from merely survival towards optimizing form and function for the burn survivor. Due to its unique structural features and functional demands however, the axilla is prone to contracture formation, and remains complex to reconstruct. Where contractures involve both the posterior and anterior axillary lines, the two facing square flaps method is a suitable choice for a wide range of patients. The flap design is flexible, and is relatively safe with a sufficient blood supply. Superior lengthening of approximately 3–4 times can be achieved, and is maintainable. In this surgical technique paper, we describe the strategy of the two facing square flaps, and present two patterns of its application, with representative cases of the local flap method.

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.