Requiring Chest Tube Research Articles

Abstract No. 351 - Efficacy of combined transarterial chemoembolization and radiofrequency ablation for treatment of single primary hepatocellular carcinomas (HCC) less than 3 cm: a single center experience

Purpose To assess overall survival at 6- and 12-months, 30-day adverse event rate, and recurrence rate within 1 year in patients treated with combination arterial chemoembolization and CT-guided radiofrequency ablation on initial presentation of small HCC Materials and Methods At our institution, 66 consecutive patients with newly diagnosed early HCC were evaluated retrospectively from Jan. 2008 - Aug. 2011 with respect to overall survival at 6- and 12-months, 30-day adverse event rate, and recurrence rate within 1 year. Patients not deemed to be surgical resection candidates as well as those awaiting liver transplant were included. Patients that had undergone prior treatment for HCC (including surgical resection) were excluded. Follow-up imaging (contrast-enhanced CT and MRI) was assessed per mRECIST criteria by a single board-certified reader. Results The 66 patients evaluated included 40 males and 26 females, varying etiologies of liver disease (39 hepatitis C, 10 hepatitis B, 8 alcoholic, 7 nonalcoholic steatohepatitis, and 2 cryptogenic), average age of presentation of 62.3 years, mean initial MELD score of 9.3, and mean index lesion size of 2.0 cm. Ten patients (15.2%) were lost to follow-up by 1 year. Of the remaining 56 patients evaluated, survival was 96.4% at 6 months and 87.5% at 12 months, including 4 out of 7 mortalities (57.1%) directly related to complications from liver transplant. Overall 30 day adverse event rate was 10.6%, including mostly minor complications: 3 subcapsular hematomas (not requiring transfusion), 3 pneumothoraces (2 requiring chest tube placement), and 1 small groin hematoma. No mortalities were seen related to combined treatment. Two patients required re-treatment due to stable disease on 1 month follow-up imaging, as determined by mRECIST criteria. Overall disease recurrence, including adjacent to and distant from the treated lesion, was seen in 15 patients (26.8%) by 1 year. Conclusion The analysis suggests that combination therapy with transarterial chemoembolization and radiofrequency ablation is efficacious for the treatment of small HCCs

Serious Air Leak Syndrome Complicating High-Flow Nasal Cannula Therapy: A Report of 3 Cases

Despite the absence of clinical safety data, heated, humidified high-flow nasal cannula (HHFNC) therapy is increasingly being used as an alternative to positive-pressure ventilation in pediatrics. This use of HHFNC is "off label" because the US Food and Drug Administration's approval for these devices was only for air humidification and not as a modality to provide positive distending pressure. For the first time we describe 3 cases who developed serious air leaks related to HHFNC therapy. The first child was a previously healthy 2-month-old male infant with respiratory syncytial virus bronchiolitis who developed a right pneumothorax on day 5 of his illness at 8 liters per minute (lpm). He subsequently required intubation and ventilation for 14 days. The second case involved an otherwise healthy 16-year-old boy with cerebral palsy who developed pneumomediastinum and died of its complications. He was receiving 20 lpm HHFNC therapy when he developed pneumomediastinum. The third case involved a 22-month-old, previously healthy boy who developed subdural hematoma secondary to abuse. He developed a right pneumothorax while receiving HHFNC at a flow of 6 lpm, requiring chest tube placement. These cases emphasize the need for extreme caution while using HHFNC for the off-label indication of providing positive distending pressure in children, especially at flows higher than the patient's minute ventilation. A more detailed study to specifically look at the serious adverse events related to HHFNC is urgently needed.

Risks of Transthoracic Needle Biopsy

Transthoracic needle lung biopsy is a commonly performed diagnostic procedure for pulmonary nodules and masses. To make an informed decision about whether to pursue this procedure, doctors and patients must be aware of the possible risks of the procedure. We performed a MEDLINE search, 2003-2012 to identify relevant English-language studies that included at least 100 subjects and reported data on complications of transthoracic needle lung biopsy performed within the last 10 years. We found the most common complication to be any pneumothorax (risk 15-25%), with pneumothorax requiring chest tube occurring less often (risk 4-6%). Hemorrhage, defined as radiographically visualized blood along the needle tract was common, but clinically significant hemorrhage was infrequent (~1%). Rare complications, including air embolism and tumor seeding of the biopsy tract, occurred in fewer than 1% of cases but were potentially serious. We summarize data on factors associated with complications, including patient age, COPD, lesion size and location, and number of punctures. We also provide data on techniques to mitigate severity of pneumothorax post-biopsy, such as rapid patient rollover, manual aspiration, and instillation of substances into the biopsy tract.

Etiologies of bilateral pleural effusions

To evaluate the safety, etiology and outcomes of patients undergoing bilateral thoracentesis. This is a prospective cohort study of 100 consecutive patients who underwent bilateral thoracenteses in an academic medical center from July 2009 through November 2010. Pleural fluid characteristics and etiologies of the effusions were assessed. Mean differences in levels of fluid characteristics between right and left lungs were tested. Associations between fluid characteristics and occurrence of bilateral malignant effusions were evaluated. The rate of pneumothorax and other complications subsequent to bilateral thoracentesis was determined. Exudates were more common than transudates, and most effusions had multiple etiologies, with 83% having two or more etiologies. Bilateral malignant effusions occurred in 19 patients, were the most common single etiology of exudative effusions, and were associated with higher levels of protein and LDH in the pleural fluid. Among 200 thoracenteses performed with a bilateral procedure, seven resulted in pneumothoraces, three of which required chest tube drainage and four were ex vacuo. More often than not, there are multiple etiologies that contribute to pleural fluid formation, and of the combinations of etiologies observed congestive heart failure was the most frequent contributor. Exudative effusions are more common than transudates when bilateral effusions are present. Malignancy is a common etiology of exudative effusions. This study suggests that the overall complication rate following bilateral thoracentesis is low and the rate of pneumothorax subsequent to bilateral thoracentesis is comparable to unilateral thoracentesis.

Abstract 9310: Gender and Outcomes Following Primary Prevention ICD Placement: Analysis of the NCDR ICD Registry

Background: Due to the small numbers of women enrolled in implantable cardioverter defibrillator (ICD) trials, outcome for women has not been well-described. This study compares intermediate-term outcomes in a large cohort of men and women receiving single or dual chamber ICDs for primary prevention. Methods: 38,912 initial implants (25% women) with single or dual chamber ICDs for primary prevention between 2006 and 2009 in the NCDR ICD Registry were identified. Baseline characteristics and outcomes, including complications, six-month heart failure (HF) readmission, and six-month mortality were compared between men and women using chi-square tests for categorical variables and unbalanced t-tests for continuous variables. Complications were considered within 30 or 90 days of implantation, including pneumothorax requiring chest tube, hematoma requiring transfusion or evacuation, tamponade, or death within 30 days, or mechanical complications with system revision, device-related infection, or post-index ICD within 90 days. The differences in outcomes between genders were also examined through multivariable logistic regression models adjusting for possible confounders. Results: Differences in baseline characteristics and drug therapy were noted between men and women (Table). Complications at 30 or 90 days, 6-month mortality, and 6-month HF readmission were significantly more frequent in women (p<0.001 for all). Differences in complications or mortality (OR 1.40, 95% CI 1.27,1.54, p<0.001), or HF readmission (OR 1.34, 95% CI 1.25, 1.44, p<0.001) persisted after adjusting for differences in baseline characteristics and device type. Conclusions: Following ICD implantation for primary prevention indications, complication rates, six-month HF readmission rates, and six-month mortality rates are higher in women than men. Whether these gender differences in outcome impact the benefit of ICDs in women requires further investigation.

S17 Pleural Irrigation Trial (PIT): Standard Care Versus Pleural Irrigation, a Randomised Controlled Trial in Patients with Pleural Infection

BackgroundPleural infection remains common with an increasing incidence. It is associated with a high morbidity and mortality. Despite chest tube drainage and antibiotic therapy up to 30% of patients will...

Percutaneous CT-guided radiofrequency ablation for unresectable hepatocellular carcinoma pulmonary metastases

Purpose: This study aimed to evaluate the safety and efficacy of percutaneous CT-guided radiofrequency ablation (RFA) for unresectable hepatocellular carcinoma pulmonary metastases (HCCPM) and to identify the prognostic factors for survival.Materials and methods: We reviewed the medical records of 320 patients with HCCPM treated between January 2005 and January 2012. Among them, 29 patients with 68 lesions of unresectable HCCPM underwent 56 RFA sessions. Safety, local efficacy, survival and prognostic factors were evaluated. Survival was analysed using the Kaplan-Meier method. Univariate analyses were evaluated by the log-rank test.Results: Pneumothorax requiring chest tube placement occurred in five (8.9%, 5/56) RFA sessions. During the median follow-up period of 23 months (range 6–70), 18 patients (62.1%, 18/29) died of tumour progression and 11 (37.9%, 11/29) were alive. The 1-, 2- and 3-year overall survival rates were 73.4%, 41.1% and 30%, respectively. The median progression-free survival was 18 months (95% confidence interval (CI) 9.8–26.2) and the median overall survival time was 21 months (95%CI, 9.7–32.3). The maximum tumour diameter ≤3 cm (p = 0.002), the number of pulmonary metastases ≤3 (p = 0.014), serum AFP level ≤400 ng/mL (p = 0.003), and the controlled status of intrahepatic tumour after lung RFA (p = 0.001) were favourable prognostic factors for overall survival.Conclusions: Our study indicates that percutaneous CT-guided RFA, as an alternative treatment procedure to pulmonary metastasectomy, can be a safe and effective therapeutic option for unresectable HCCPM.

Feasibility of Pulmonary Interstitial Lymphography-guided Targeting in Stereotactic Ablative Radiation Therapy of Lung Tumors

71 patients whose MPLCs were both stage I, overall survival rates were 68.7% at 3 years and 28.1% at 5 years, with median survival time 59.8 months. Survival seemed better for MMPLC than for SMPLC, but this was not statistically different. In multivariate analysis, poor survival was associated with having CFRT for an index tumor (p Z 0.035) and being oxygen-dependent before treatment (p Z 0.019). Survival rates were not different for patients whose index tumors were treated with SABR versus surgery. The most common toxicity of SABR was chest wall pain (21.8% grade 2 and 3% grade 3), followed by pneumonitis (13.5% grade 2 and 3.1% grade 3/4) and dermatitis (9.4% grade 2 and 1% grade 3). Conclusions: SABR produced excellent local control and survival with tolerable toxicity in MPLC and may be potentially curative in some cases. Author Disclosure: Y. Liu: None. P. Balter: None. R. Komaki: None. Q. Xu: None. S. Swisher: None. J. Chang: None.

Relationship Between Pulmonary Artery Invasion and High-dose Radiation and Overall Survival in Patients With Non-small Cell Lung Cancer

(51 54%), and 40% (38 43%) with SBRT (P > 0.05). In view of acute toxicity, the most frequent complication of RFA is pneumothorax, which occurs in 32% (16 45%) patients, required chest tube insertion in 12% (7 39%) of patients. Conclusions: Local control rate for SBRT is significantly higher than that for RFA, though overall survival seems not significantly different between two treatment groups. However, caution is warranted due to the relatively limited number of RFA and short follow-up time. Author Disclosure: N. Bi: None. K. Shedden: None. X. Zheng: None. W. Wang: None. F. Kong: None.

Patients’ survival in lung malignancies treated by microwave ablation: our experience on 56 patients

ObjectivesWe retrospectively evaluated percutaneous CT-guided microwave (MW) ablation safety and efficacy in unresectable lung malignancies focusing on patients’ survival. Materials and methodsAll procedures were approved by the hospital ethical committee. From 2008 to 2012 we treated 69 unresectable lesions (44 lung cancer, 25 lung metastases) in 56 patients (35 men/21 women; mean age: 61.5years). Treatment was performed under CT guidance using 14G needles with a 3cm active tip and a 55W MW generator (Vivawave Microwave Coagulation System; Valley Lab). Treatment was performed at 45W for 6–10min. Patients were scheduled for a 3 and 6month CT follow-up to evaluate lesion diameter and enhancement. Survival rate was evaluated by Kaplan–Meier analysis. ResultsAblation procedures were completed according to protocol in all patients. Pneumothorax occurred in 18 patients and 8 required chest tube. Four lesions (all >4.3cm) were retreated 20days after the ablation because of peripheral focal areas of residual tumor. Follow-up CT evaluation showed a decrease in maximum diameter in 44/69 lesions (64%) and in 42/59 lesions (71%) at 3 and 6months, respectively. In all cases no pathologic enhancement was observed. Cancer-specific mortality yielded a survival rate of 69% at 12months, 54% at 24months and 49% at 36months, respectively. An estimate mean for survival time was 27.8months with a standard error of 2.8months (95% confidence interval: 22.4–33.2months). ConclusionBased on our experience, MW ablation seems to represent a potential safe and effective percutaneous technique in the treatment of lung malignancies. MW ablation may improve survival in patients not suitable to surgery.

Simultaneous Computed Tomography-Guided Biopsy and Radiofrequency Ablation of Solitary Pulmonary Malignancy in High-Risk Patients

Background: In recent years experience has been accumulated in percutaneous radiofrequency ablation (RFA) of lung malignancies in nonsurgical patients. Objectives: In this study, we retrospectively evaluated a simultaneous diagnostic and therapeutic approach including CT-guided biopsy followed immediately by RFA of solitary malignant pulmonary lesions. Methods: CT-guided transthoracic core needle biopsy of solitary pulmonary lesions suspicious for malignancy was performed and histology was proven based on immediate frozen sections. RFA probes were placed into the pulmonary tumors under CT guidance and the ablation was performed subsequently. The procedure-related morbidity was analyzed. Follow-up included a CT scan and pulmonary function parameters. Results: A total of 33 CT-guided biopsies and subsequent RFA within a single procedure were performed. Morbidity of CT-guided biopsy included pulmonary hemorrhage (24%) and a mild pneumothorax (12%) without need for further interventions. The RFA procedure was not aggravated by the previous biopsy. The rate of pneumothorax requiring chest tube following RFA was 21%. Local tumor control was achieved in 77% with a median follow-up of 12 months. The morbidity of the CT-guided biopsy had no statistical impact on the local recurrence rate. Conclusions: The simultaneous diagnostic and therapeutic approach including CT-guided biopsy followed immediately by RFA of solitary malignant pulmonary lesions is a safe procedure. The potential of this combined approach is to avoid unnecessary therapies and to perform adequate therapies based on histology. Taking the local control rate into account, this approach should only be performed in those patients who are unable to undergo or who refuse surgery.

1278 Outcome Following Fetal Pleuroamniotic Shunting in 114 Large Hydrothoraces

IntroductionUntreated, fetal hydrothorax is associated with significant morbidity and a mortality rate of approximately 80–90%.Population114 fetuses with isolated large pleural effusions underwent pleuroamniotic shunting at our perinatal centre. All had...

Masked Pneumothorax: Risk of Valveless Trocar Systems

Unlike traditional valved trocars, the valveless trocar maintains pneumoperitoneum during laparoscopy by forming a CO(2) curtain at the proximal end of the trocar. This gas barrier instantaneously maintains exact intraperitoneal pressure that yields to the transient physiological changes seen with breathing. Due to this different mechanism of action, pneumothorax development may be masked by the valveless trocar system. We retrospectively reviewed 850 transperitoneal laparoscopic kidney and adrenal surgeries in which a valveless trocar system was used to determine any record of pneumothorax detected intraoperatively or postoperatively. A patient with pneumothorax was considered a case and anesthetic parameters were reviewed. A matched control group was generated from patients treated with transperitoneal laparoscopic kidney and adrenal surgery using the valveless trocar with no complications. Pneumothorax was diagnosed in 10 patients (1.2%). Two cases were the result of intentional excision of the diaphragm, which were repaired intraoperatively, while 8 were not recognized until the postoperative period. Five of the patients (63%) with unintentional pneumothorax required chest tube placement for a mean of 2.4 days. The remaining 3 patients (37%) were treated conservatively and followed with serial chest x-rays. The only anesthetic variable that was significantly different between the groups was Δ end tidal CO(2) with greater fluctuations in end tidal CO(2) in the pneumothorax group than in controls (p = 0.03). Pneumothorax is a rare complication of laparoscopic urological surgery that is usually recognized intraoperatively through physiological changes. Valveless trocar systems mask these findings and can delay identification until the postoperative period.

"Page Me if You Need Me": The Hidden Curriculum of Attending-Resident Communication.

Discrepancies exist between what resident and attending physicians perceive as adequate supervision. We documented current practices in a university-based, categoric, internal medicine residency to characterize these discrepancies and the types of mixed messages that are communicated to residents, as well as to assess their potential effect on resident supervision and patient safety. We surveyed residents and attending physicians separately about their current attitudes and behaviors regarding resident supervision. Both groups responded to 2 different measures of resident supervision: (1) 6 clinical vignettes that involved patient safety concerns, and (2) 9 frequently reported phrases communicated by attending physicians to residents before leaving the hospital during on-call admission days. There were clear and substantial differences between the perceptions of resident and attending physicians about when the supervising attending physician should be notified in each of the 6 vignettes. For example, 85% of attending physicians reported they wanted to be notified of an unexpected pneumothorax that required chest tube placement, but only 31% of resident physicians said they would call their attending physician during those circumstances. Common phrases, such as "page me if you need me," resulted in approximately 50% of residents reporting they would "rarely" or "never" call and another 41% reporting they would only "sometimes" call their attending physicians. Our study found that attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians. Although this discrepancy exists, commonly used phrases, such as "page me if you need me," rarely resulted in a change in resident behavior, and attending physicians appeared to be aware of the ineffectiveness of these statements. These mixed messages may increase the difficulty of balancing the dual goals of appropriate attending supervision and progressive independence during residency training.

Population-based estimates of transbronchial lung biopsy utilization and complications

Little is known about trends in the utilization or complication rates of transbronchial lung biopsy, particularly in community hospitals. We used the Healthcare Cost and Utilization Project Florida State Inpatient and State Ambulatory Surgical Databases to assess trends in transbronchial lung biopsy utilization in adults from 2000 to 2009. We subsequently calculated population based estimates of complications associated with transbronchial lung biopsy (iatrogenic pneumothorax and procedure-related hemorrhage) and identified characteristics associated with complications. From 2000 to 2009, the age-adjusted rate of transbronchial biopsies per 100,000 adults in Florida decreased by 25% from 74 to 55 (p<0.0001), despite stability in the overall utilization of bronchoscopy. Analysis of 82,059 procedures revealed that complications associated with transbronchial biopsy were uncommon and stable over the study period, with 0.97% (95% CI 0.94-1.01%) of procedures complicated by pneumothorax, 0.55% (95% CI 0.52-0.58%) by pneumothorax requiring chest tube placement, and 0.58% (95% CI 0.55-0.61%) by procedure-related hemorrhage. Patients with COPD (OR 1.51, 95% CI 1.31-1.75) and women (OR 1.32, 95% CI 1.15-1.52) were at increased risk for pneumothorax, while renal failure (OR 2.85, 95% CI 2.10-3.87), cirrhosis (OR 2.31, 95% CI 1.18-4.52), older age (OR 1.17, 95% CI 1.09-1.25) and female sex (OR 1.40, 95% CI 1.17-1.68) were associated with higher risk of procedure-related hemorrhage. Utilization of transbronchial lung biopsy is decreasing relative to the overall use of bronchoscopy. Nevertheless, it remains a safe procedure with low risk of complications.

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

BackgroundAcute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART).Methods/DesignART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH2O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure ≤30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle.DiscussionIf the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Trial registrationClinicalTrials.gov Identifier: NCT01374022

Occult hemopneumothorax following chest trauma does not need a chest tube.

The increasing use of thoracic computed tomography (CT) in trauma patients has led to the recognition of intrapleural blood and air that are not initially evident on admission plain chest X-ray, defining the presence of occult hemopneumothorax. The clinical significance of occult hemopneumothorax, specifically the role of the tube thoracostomy, is not clearly defined. To identify those patients with occult hemopneumothorax who can be safely managed without chest tube insertion. Prospective observational study. During the recent 24month period ending July 2010, comprehensive data on trauma patients with occult hemopneumothorax were recorded to determine whether tube thoracostomy was needed and, if not, to define the consequences of nondrainage. Pneumothorax and hemothorax were quantified by computed tomography (CT) measurement. Data included demographics, injury mechanism and severity, chest injuries, need for mechanical ventilation, indications for tube thoracostomy, hospital length of stay, complications and outcome. There were 73 patients with hemopenumothorax identified on CT scan in our trauma registry. Tube thoracostomy was successfully avoided in 60 patients (83%). Indications for chest tube placement in 13 (17%) of patients included X-ray evidence of hemothorax progression (10), respiratory compromise with oxygen desaturation (2). Mechanical ventilation was required in 19 patients, five of them required chest tube insertion, and six developed ventilator associated pneumonia, while there were no cases of empyema. There was one death due to severe head injury. Occult hemopneumothorax can be successfully managed without tube thoracostomy in most cases. Patients with a high ISS score, need for mechanical ventilation, and CT-detected blood collection measuring >1.5cm increased the likelihood of need for tube thoracostomy. The size of the pneumothorax did not appear to be significant in determining the need for tube thoracostomy.

Vertebral Column Resection in Children With Neuromuscular Spine Deformity

Retrospective analysis. To determine, in pediatric patients with neuromuscular deformity undergoing vertebral column resection (VCR), the (1) characteristics of the surgery performed; (2) amount of pelvic obliquity restoration, and coronal and sagittal correction achieved; (3) associated blood loss and complications; and (4) extent to which curve type and VCR approach influenced correction, blood loss, and complications. VCR allows for correction of severe, rigid spinal deformity. This technique has not been previously reported in children with neuromuscular disorders. We retrospectively reviewed the records of 23 children with neuromuscular disorders (mean age, 15 years) and spinal deformities (severe scoliosis, 9; global kyphosis or angular kyphosis, 4; kyphoscoliosis, 10) who underwent VCR. The Student t test was used to compare correction differences (statistical significance, P < 0.05). A mean 1.5 vertebrae (27 thoracic and 6 lumbar) were resected per patient. Significant corrections were achieved in pelvic obliquity (11°, from 19° ± 13° to 8° ± 7°), in major coronal curve (56°, from 94° ± 36° to 38° ± 20°), and in major sagittal curve (46°, from 86° ± 37° to 40° ± 19°). There was no difference in correction between various curve types. VCR was associated with substantial blood loss (mean, 76% [estimated blood loss per total blood volume]), which correlated with patient weight and operating time. Overall, 6 patients experienced major complications: spinal cord injury, pleural effusion requiring chest tube insertion, pneumonia, pancreatitis, deep wound infection, and prominent implant requiring revision surgery. There were no deaths or permanent neurological injuries. VCR achieved significant pelvic obliquity restoration and coronal and sagittal correction in children with neuromuscular disorders and severe, rigid spinal deformity. However, this challenging procedure involves the potential for major complications.

Right-side Chest Wall Prominence

A 4-month-old premature infant with a history of tracheoesophageal fistula ligation at birth presents with right-side chest wall prominence 1 month after repair of the esophageal atresia. ### Birth History and Early Hospital Course On day 2, the infant underwent division and ligation of the fistula with gastrostomy tube placement. Surgery was complicated by the development of a right-sided chylothorax requiring chest tube placement for drainage and octreotide therapy, which resolved by age 3½ months. The patient underwent right thoracotomy and esophageal atresia repair at age 3 …

Minimally invasive lateral extracavitary corpectomy: cadaveric evaluation model and report of 3 clinical cases

In this paper, the authors' goal was to demonstrate the clinical and technical nuances of a minimally invasive lateral extracavitary approach (MI-LECA) for thoracic corpectomy and anterior column reconstruction. A cadaveric feasibility study and the subsequent application of this approach in 3 clinical cases are reported. Six procedures were completed in 3 human cadavers. Minimally invasive, extrapleural thoracic corpectomies were performed with the aid of a 24-mm tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT scanning, using 3D volumetric averaging software, was used to evaluate the degree of bone removal and decompression. Three clinical cases, including a T-11 burst fracture, a T-7 plasmacytoma, and a T4-5 vertebral body (VB) tuberculosis lesion, were treated using the approach. At 6 cadaveric levels, the mean circumferential volumetric decompression was 48% ± 16%, and the mean resection of the VB was 72% ± 13%. The mean change in anterior and posterior vertebral height with expansion of the corpectomy cage was 47 and 61 mm, respectively. There were no violations of the pleura or dura. Pedicle screw reliability was 95.8% (23 of 24 screws) with a single lateral breach. All 3 patients in the clinical cohort had excellent clinical outcomes. There was a single pleural tear requiring chest tube drainage. Operative images and a video clip are provided to illustrate the approach. A minimally invasive lateral extracavitary thoracic corpectomy has the ability to provided excellent spinal cord decompression and VB resection. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to improve upon established traditional open corridors for posterolateral thoracic corpectomy.