Right-sided Thoracotomy Research Articles

Isolated “on-pump” tricuspid valve repair through right-sided anterolateral thoracotomy by modified femoral-monocaval cannulation in patients with repeated heart intervention – a safe and effective surgical alternative

Isolated “on-pump” tricuspid valve repair through right-sided anterolateral thoracotomy by modified femoral-monocaval cannulation in patients with repeated heart intervention – a safe and effective surgical alternative

The contemporary approach to chylothorax – Single-center experience with the proposal of a management algorithm

Objectives: Chylothorax is a relatively rare condition of lymphatic fluid accumulation in the thoracic cavity due to a leakage from the thoracic duct or its tributaries. Patients present with dyspnea, malnutrition, and immunosuppression. Treatment can be conservative or surgical, depending on etiology and clinical course. The optimal management algorithm for chylothorax is still controversial. Methods: This is a ten-year period retrospective study of all patients with chylothorax treated at our Department of Thoracic Surgery. Results: A total of 14 patients were identified for the study. Nine patients had chylothorax after lung or esophageal cancer surgery. Four patients had chylothorax in advanced lymphoma. One patient had chylothorax after blunt chest trauma. A conservative approach was initiated in most patients (92%), including pleural drainage, nil per mouth, total parenteral nutrition, and somatostatin 0.1 mg bid subcutaneously. Surgical treatment was indicated in patients with thoracic drain production >800 mL per day beyond the fifth day of treatment and those with blunt thoracic trauma. Two patients had thoracic duct ligation via right-sided thoracotomy, and five patients had video-assisted thoracoscopic thoracic duct ligation with the immediate arrest of chylous leakage. Conclusion: Chylothorax should be treated conservatively initially. Surgical treatment should not be delayed beyond the fifth day in case of failure. In our series of patients, a video-assisted thoracoscopic approach for thoracic duct ligation proved to be minimally invasive, highly efficient, and well tolerated. Therefore, it should be the preferable route of surgical treatment.

A rare clinical case of malignant ectopic retrosternal goiter of a large size in a patient with aberrant right subclavian artery

Background. Ectopic goiter accounts for only 0.2 % to 1 % of all mediastinal goiters. The aberrant right subclavian artery (arteria lusoria) is an extremely rare anomaly of the major vessel, with a prevalence not exceeding 0.3 % in the general population. This paper presents the first case of malignant ectopic retrosternal goiter of a large size in combination with the aberrant right subclavian artery. Clinical case description. A 61-year-old male presented to the thoracic surgery department of P. Herzen Moscow oncology Research institute with a large posterior mediastinal mass measuring 108×106×79 mm and adjacent to the right lobe of the thyroid gland. The tumor displaced the trachea and esophagus. Open biopsy through a thoracotomy incision revealed thyroid gland cells without signs of atypia. A detailed examination revealed mediastinal vascular anomaly – retrotracheal position of the right subclavian artery. a complete longitudinal sternotomy, complemented by a right-sided thoracotomy at the 3rd intercostal space, served as the surgical approach. The operation lasted 320 minutes, with a blood loss of 3500 ml. The postoperative period was uneventful. The morphological examination of the surgical specimen revealed nodular hyperplasia of the ectopic thyroid tissue with the growth of well-differentiated follicular carcinoma without metastatic involvement of removed lymph nodes. Considering the identified follicular carcinoma, total thyroidectomy was performed. Conclusion. In surgical planning, it is crucial to assess the location of major mediastinal vessels and their relationship with the goiter. Therefore, all patients with mediastinal lesions should undergo preoperative contrast-enhanced ct. Retrosternal goiter predisposes to a higher rate of malignancy compared to cervical goiter. If the lower edge of the goiter is at the level of or below the aortic arch, cervical access should be supplemented with sternotomy. In cases of a massive thoracic component, additional thoracotomy is justified.

Novel Left-Sided Thoracoscopic Approach to Recurrent Tracheoesophageal Fistula and Post-Fistula Tracheal Diverticula

Background: Recurrent tracheoesophageal fistula (RTEF) is usually a consequence of leakage or other complications after esophageal atresia repair performed through right-sided access. This results in extensive intrapleural adhesions, and open redo surgery poses a challenge. Alternatively, endoscopic endotracheal fistula obliteration usually requires repetitive procedures, and its success rate varies significantly between centers. We present a novel approach to recurrent fistulas. The innovation is in reaching the fistula through the virgin field via left-sided three-port thoracoscopy instead of classical right-sided thoracotomy. Methods: This is a presentation of a new operative technique based on a retrospective case series of patients operated on at our department between 2016 and 2023. Results: Eight patients after esophageal atresia repair (six with RTEF and two with post-fistula tracheal diverticula) were successfully treated with left-sided thoracoscopy. There were no conversions. One patient required rethoracoscopy for chylothorax. Another one, after RTEF closure, underwent multiple endoscopic obliterations of subsequent tracheal diverticulum. No other major complications nor re-recurrences were noted. Conclusions: Left-sided thoracoscopy in redo esophageal atresia has the advantage of a “virgin” operative field and grants feasible access to the RTEF or tracheal diverticulum. We believe that this approach is worth further exploration because it combines minimal invasiveness with high effectiveness without all the consequences of a thoracotomy.

SAT539 Thyroid Cancer Presenting as Aspiration Pneumonia

Abstract Disclosure: S. Aslam: None. M. Asif: None. I. Nadeem: None. W.J. Khan: None. Background Goiter, most often, is first noticed as a visible neck mass; however, some patients may present with signs and symptoms of hypothyroidism, or hyperthyroidism. Retrosternal extension can cause compression of the trachea, esophagus, and jugular veins resulting in dysfunction of these viscera. CaseA 68-year-old male presented with SOB, and weakness for 5 days. He had SaO2 79% on room air requiring oxygen, RR 28/min, HR 78/min and Temp.101.6 F, BP 94/48 mmHg. The lung exam revealed bilateral rhonchi and coarse crypts. Minimal non-tender nodularity was noted on the thyroid palpation not previously noticed by the patient or his family. Chest x-ray showed bilateral airspace opacities. CT chest revealed a large upper mediastinal mass displacing the trachea and esophagus to the right, a nodule in the left lobe of thyroid, subcarinal and right hilar lymphadenopathy and bilateral dependent consolidative opacities suggesting aspiration pneumonia but no PE. A barium esophagogram showed a 7.5 cm mediastinal mass causing 50% narrowing and displacement of esophagus and compression with left sided deviation of trachea. A barium swallow study was done, and the patient was found to have aspiration with all administered food types due to an abnormal swallowing mechanism. The patient was advised NPO and placed on NG tube feeding to prevent further aspiration. The patient underwent bronchoscopy and EBUS from station 4 lymph node, the pathology of which did not show any malignant cells. However, due to high clinical suspicion of a malignant process, the patient underwent a CT-guided biopsy of the mediastinal mass that showed bland thyroid tissue. Ultrasound of thyroid revealed multiple right and left lobe nodules. TSH and free T4, and calcitonin were WNL. The patient's hypoxia and fever resolved after completion of the antibiotics including ceftriaxone and doxycycline and being nothing per oral within 7 days. Due to persistent dysphagia, he was placed on PEG tube feeding and discharged from the hospital to a nursing home. The patient underwent ultrasound-guided fine needle biopsy of 1 right-sided and 2 left-sided thyroid nodules that resulted as papillary thyroid cancer. He underwent a successful right-sided thoracotomy and removal of large sized thyroid mass. The patient is seeing endocrinology as an outpatient for radioactive iodine and hormone replacement therapy. Conclusion We treated a patient of follicular carcinoma who presented with extrathyroidal symptoms. Retrosternal or ectopic thyroid tumors can present as euthyroid state without obvious enlargement of the normal thyroid gland. A meticulous clinical evaluation should include the differential diagnosis of retrosternal goiter or ectopic thyroid with cancer when treating patients who preset with sign and symptoms concerning for mediastinal disease. Presentation Date: Saturday, June 17, 2023

Pulmonary artery aneurysm-related fatal hemoptysis in Behcet's disease: A case report with literature review

Introduction: Behcet's disease is a multisystemic disorder of unknown etiology. Vascular involvement is identified by the development of aneurysms and occlusion of the vessels. the current report aimed to discuss a case of Behcet disease presented with a bilateral pulmonary aneurysm.
 Case presentation: A 41-year-old woman presented with recurrent attacks of hemoptysis for two years. a chest computed tomography scan bilateral pulmonary artery aneurysm. Repeated bronchoscopy showed bleeding from the right lower lobe bronchus. She underwent a right-side thoracotomy with a right lower lobectomy. She was scheduled for left-side intervention as well. Before discharge, she was seen by a rheumatologist and was diagnosed with a case of Behcet disease. She developed attacks of massive hemoptysis (huge and bright blood) after two weeks which led to her passing away.
 Conclusion: Although it is rare, Behcet disease could involve major arteries and lead to fatal complications. Surgical intervention remained a viable option for the management.

Resection of a schwannoma originating from vagus nerve in the right superior mediastinum

BackgroundSchwannoma is the most common mediastinal neurogenic tumor, while schwannoma originating from mediastinal vagus nerve is rare.Case presentationThis article reported one case of schwannoma originating from vagus nerve in the right superior mediastinum. The mediastinal schwannoma was completely resected through a right-sided video-assisted thoracoscopic thoracotomy. Histologic examination clarified the diagnosis as schwannoma.ConclusionChest CT scan and MRI can be used to determine the location of mediastinal schwannoma and its relationship with adjacent tissue. Histologic examination showing distinctive feature of Antoni A areas and Antoni B areas can help clarify the diagnosis. Complete surgical resection is the first-line treatment option for mediastinal schwannomas.

Physiotherapy management in the case of thoracotomy for right lung decortication: A case study

Thoracotomy is used to manage a variety of medical conditions, including lung cancer, pulmonary infections, and chest injuries. Decortication surgery is indicated in the case of a thickened pleural layer leading to atelectasis of the underlying lung parenchyma. It is done to prevent further restriction of the lung parenchyma. Atelectasis, pleural effusion, pneumonia, and consolidation following decortication are common complications of the surgery. Physiotherapy following decortication helps in preventing damage to the lungs and also helps in maintaining and regaining good lung function postsurgery. This is a right-sided lung decortication thoracotomy surgical procedure where physiotherapy interventions were given preoperatively and early postsurgical care was taken for adequate lung expansion and to reduce respiratory complications following it. Incentive spirometer (4 times/day) with breath hold technique (3 s.) along with conventional physiotherapy interventions such as chest mobility exercise, breathing exercises, breath control techniques, and early mobilization in the form of long sitting at the end of a bed, high sitting, chair sitting, standing, walking, and stair climbing were improved in chest expansion, functional activities, rating of perceived exertion level, and reduced pain level.

Living-Related Liver Retransplantation in a Child: When it Seems Impossible (A Clinical Case)

The objective: to show the possibility of anesthesia during liver retransplantation in a child in the absence of adequate vascular access.A clinical case of liver retransplantation in a 10-year-old patient with liver transplant dysfunction and acquired thrombophilia is considered. In 2011, the child underwent Kasai portoenterostomy, and in 2012, living-related transplantation of the left lateral liver bisegment from a related donor was performed due to liver cirrhosis as an outcome of biliary atresia. Also, the child had multiple surgical interventions due to perforations of the small intestine with underlying segmental venous mesenteric thrombosis. In the long term after the transplantation, irreversible transplant dysfunction developed with manifestations and worsening of hepatocellular insufficiency, encephalopathy, as well as recurrent bleeding from varicose veins of the esophagus and cardiac orifice. The clinical situation was complicated by the lack of adequate vascular access due to total thrombosis of the venous system, thrombosis of the superior and inferior vena cava. The only possible option for ensuring adequate venous access was the implantation of a tunneled catheter into the right atrium of the right atrium for prolonged standing in conditions of single-lung ventilation through right-sided thoracotomy.

Consolidation Intensity-Modulated Whole Abdominal Radiotherapy as Part of the Complex Treatment for Metastatic Adrenocortical Carcinoma in Adolescence

Adrenocortical carcinoma (ACC) is an extremely rare solid malignant tumor. We present rare local advanced ACC with lung metastases in adolescence. After visible radical surgery for a 100mm/130mm/50mm tumor, the initial histological diagnosis was anaplastic pleomorphic neuroblastoma originating from the left adrenal gland. Despite the eight courses chemotherapy, the disease progression was reported, which requires a pathohistological revision with a broad immunohistochemical (IHC) analysis. After surgical excision of peritoneal metastases, a system Ch alteration of Vincristine/ Cyclophospamide/Farmarubicin and Vepesid/ Cisplatin - on 4 blocks each, in combination with the constant intake of Mitotane (Lesydren) was performed. Due to the disease progression, a consolidation intensity modulated radiotherapy (IMRT) of the right lung metastasis measuring 23 mm/ 16 mm with PET/ CT hypermetabolic activity/ SUV max 9,67 and of a vertebral L2 metastasis was performed. In December 2021, a right-sided thoracotomy with resection of three pulmonary metastases, followed by pulmonary segmentectomy of the irradiated right-sided lung metastasis was performed. The peritoneal metastatic dessimination necessitated a consolidation whole abdominal IMRT with boost in the tumor bed/ upper pole of the left kidney. With this rare clinical case, we emphasize the role of complex treatment, especially with respect to local oncological therapy (surgery and IMRT) in metastatic adolescence ACC. Despite metastatic disease, complex treatment achieves a 3 -year survival rate

Diagnostic and Therapeutic Challenges in Treating an Esophago-Pleural Fistula Following Lung Transplantation

Introduction Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). Case Report A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Summary Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective. Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective.

Surgical Treatment for Advanced Thoracic Spinal Tuberculosis in Infants: Case Series and Literature Review.

Spinal tuberculosis (TB), or Pott's disease, is the most common form of osteoarticular TB. Early diagnosis and anti-TB drug therapy are the mainstays of treatment. However, in advanced stages, surgery is essential to correct spinal deformities and avoid neurological damage. Very few cases in young children requiring surgical treatment have been described. We present 2 cases of surgically treated thoracic spinal TB in patients under 2 years of age and review the literature on this entity in young children. Two male toddlers, aged 21 (patient 1) and 23 (patient 2) months, were admitted due to insidious systemic deterioration associated with neck stiffness and nonspecific abdominal pain in patient 1 and limping in patient 2. The findings of laboratory tests were unremarkable despite an increase in acute-phase reactants. After an extensive workup, results of a magnetic resonance imaging were consistent with spinal TB in both patients. Patient 1 underwent costotransversectomy of the left third and fourth ribs, debridement, T3-T4 corpectomy, and T2-T6 posterior fusion, to which an anterior rib autograft was added. Patient 2 had a right-sided thoracotomy performed at the apex in addition to debridement and T8 corpectomy; the resected rib was used as anterior structural autograft. Several samples of purulent, caseous material were sent for study. On follow-up, progression of proximal junctional kyphosis was evidenced in patient 1, requiring revision surgery to restore sagittal alignment; the patient was asymptomatic at 2-year follow-up. Patient 2 evolved satisfactorily without neurological sequelae and was asymptomatic at 4-year follow-up. Spinal TB in young children requires appropriate surgical treatment when presenting at advanced stages or having severe deformity or neurological compromise. Despite the challenges associated with young age and ongoing growth, surgery can be performed safely provided proper surgical expertise. After extensive debridement and decompression, priority should be given to restoring sagittal alignment and balance with stable and durable spinal reconstructions.

Effects of Body Position and Hypovolemia on the Regional Distribution of Pulmonary Perfusion During One-Lung Ventilation in Endotoxemic Pigs

Background: The incidence of hypoxemia during one-lung ventilation (OLV) is as high as 10%. It is also partially determined by the distribution of perfusion. During thoracic surgery, different body positions are used, such as the supine, semilateral, lateral, and prone positions, with such positions potentially influencing the distribution of perfusion. Furthermore, hypovolemia can impair hypoxic vasoconstriction. However, the effects of body position and hypovolemia on the distribution of perfusion remain poorly defined. We hypothesized that, during OLV, the relative perfusion of the ventilated lung is higher in the lateral decubitus position and that hypovolemia impairs the redistribution of pulmonary blood flow.Methods: Sixteen juvenile pigs were anesthetized, mechanically ventilated, submitted to a right-sided thoracotomy, and randomly assigned to one of two groups: (1) intravascular normovolemia or (2) intravascular hypovolemia, as achieved by drawing ~25% of the estimated blood volume (n = 8/group). Furthermore, to mimic thoracic surgery inflammatory conditions, Escherichia coli lipopolysaccharide was continuously infused at 0.5 μg kg−1 h−1. Under left-sided OLV conditions, the animals were further randomized to one of the four sequences of supine, left semilateral, left lateral, and prone positioning. Measurements of pulmonary perfusion distribution with fluorescence-marked microspheres, ventilation distribution by electrical impedance tomography, and gas exchange were then performed during two-lung ventilation in a supine position and after 30 min in each position and intravascular volume status during OLV.Results: During one-lung ventilation, the relative perfusion of the ventilated lung was higher in the lateral than the supine position. The relative perfusion of the non-ventilated lung was lower in the lateral than the supine and prone positions and in semilateral compared with the prone position. During OLV, the highest arterial partial pressure of oxygen/inspiratory fraction of oxygen (PaO2/FIO2) was achieved in the lateral position as compared with all the other positions. The distribution of perfusion, ventilation, and oxygenation did not differ significantly between normovolemia and hypovolemia.Conclusions: During one-lung ventilation in endotoxemic pigs, the relative perfusion of the ventilated lung and oxygenation were higher in the lateral than in the supine position and not impaired by hypovolemia.

Right thoracotomy - an alternative surgical access in the surgery of congenital heart defects

Background: In this report presented the results of surgical correction in septal defects associated with congenital heart defects from right-sided lateral thoracotomy. Carried out comparative assessment of perioperative indicators, such as the duration of the operation, the duration of artificial circulation, the duration of artificial ventilation of the lungs, the time of staying patients in the intensive care unit and postoperative hospital days in patients operated from right-sided lateral thoracotomy and standard longitudinal sternotomy. Methods: Were analyzed the results of surgical treatment of 150 patients with isolated heart septal defects, a combination of heart septal defects with pulmonary artery stenosis, with anomalies of the inflow of the pulmonary veins, with atrioventricular valve pathologies, as well as with aortic valve insufficiency. All patients were divided into two groups of equal number of patients. I - group (main group) of 75 patients operated on from a right-sided lateral thoracotomy. II - group (control group) 75 patients operated on from a median longitudinal sternotomy. Results: In the group of patients operated from lateral thoracotomy, there was a significant reduction in the total duration of operation, a shortening of the time of artificial lung ventilation, the length of stay of patients in the intensive care unit and reduction of postoperative hospital days. The duration of cardiopulmonary bypass among patients of both groups did not differ significantly, being 35.6 ± 3.45 minutes in the main group, and 39.48 ± 3.48 minutes in the control group, p = 0.43. All performed operations from right-sided thoracotomy access proceeded without technical difficulties, and the stages of elimination of existing defects were carried out in full according to the standard protocol. In no case was there a need for conversion. Patients were particularly satisfied with the achieved cosmetic effect. Conclusions: Based on the obtained results, the authors of the report came to the conclusion that right-sided thoracotomy can be used as an alternative surgical access to the standard sternotomy access in the surgery of septal defects and some congenital heart defects associated with it in conditions of artificial circulation. This access is less traumatic, better tolerated by patients and subsequently gives fewer complications

Bilateral secondary pulmonary tuberculosis complicated with bilateral chylothorax: a case report

A 26-year-old female was admitted to the emergency department of thoracic surgery complaining of chest tightness, shortness of breath, and a history of bilateral tuberculosis. A chest Computed Tomography (CT) scan showed bilateral pleural effusion. After that, the patient was implanted with bilateral intercostal drainage tubes. Further analysis of the pleural effusion was conducted to confirm the diagnosis of bilateral chylothorax. We initiated conservative treatment consisting of fasting and total parenteral nutrition. After the failure of conservative treatment, the patient underwent ligation of the thoracic duct by right-sided thoracotomy combined with talc slurry. On the first day postoperatively, the right pleural effusion had decreased significantly, while the left pleural effusion had not. Subsequently, talc slurry was injected into the left thoracic drainage tube of the patient. Bilateral pleural effusion was significantly reduced. Re-examination chest X-ray showed the disappearance of pleural effusion, and the patient was discharged good healthy. Chest X-rays were reexamined one month postoperatively, and the patient's lung was well dilated, with no recurrence of pleural effusion. In this case, it was shown that conservative treatment is the first choice for chylothorax. However, if this proves to be ineffective, early surgical treatment should be considered. Early diagnosis and timely surgical intervention are the key factors to improve the prognosis of patients.

Comparative analysis of the results of cardiac surgery via median sternotomy and right-sided thoracotomy

Comparative analysis of the results of cardiac surgery via median sternotomy and right-sided thoracotomy

Retrosternal goiter in thoracic surgical practice

To evaluate and optimize surgical approaches to the management of retrosternal goiter. A cohort retrospective single-center study included 56 patients aged 68.3±9.8 years with retrosternal goiter who underwent surgery between 2004 and 2019. Right-sided goiter was diagnosed in 16 cases, left-sided goiter in 21 patients, bilateral goiter in 19 patients. Palpable neck mass was found in 17 (30.4%), stridor in 16 (28.6%), thyrotoxicosis in 4 (7.1%) and recurrent laryngeal nerve palsy in 2 (3.6%) cases. X-ray signs of tracheal compression were detected in 43 (76.8%) patients, deviation in 26 (46.4%) patients. Resection through cervical collar incision was performed in 40 (71.4%) patients. Additional sternotomy was required in 11 (19.6%) patients, 1 (1.8%) patient required collar incision and right anterior mediastinotomy. Right-sided posterolateral thoracotomy without collar incision was performed in 1 (1.8%) patient with a suspected mediastinal teratoma. Three patients underwent median sternotomy only because of preoperative diagnosis of teratoma in one and thymoma in two patients. There was no perioperative mortality. Transient vocal changes occurred in 3 (5.4%) patients, recurrent laryngeal nerve palsy in 3 (5.4%), atrial fibrillation in 2 (3.6%), wound complications in 2 (3.6%), left phrenic nerve palsy in 1 (1.8%), transient hypocalcaemia in 1 (1.8%) and persistent hypothyroidism in 1 (1.8%) patient. Hospital-stay ranged from 2 to 12 (5.5±2.0) days. Multinodular goiter was found in 53 (94.6%) patients, diffuse goiter in 1 (1.8%), ectopic thyroid in 1 (1.8%) and oncocytic tumor in 1 (1.8%) patient. One (1.8%) patient underwent simultaneous resection of RSG via a collar incision and right-sided VATS upper lobectomy for primary lung cancer. One (1.8%) patient also underwent simultaneous resection of RSG via collar incision and right-sided VATS subcarinal lymph node biopsy for coexistent lymphoma. Mean vertical length of goiter in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. Mean weight of specimens was 162.3 g in patients with collar incisions and 312.5 g in the sternotomy group. Sternotomy was required in 14 (25%) patients. Resection of retrosternal goiter is more commonly performed via cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the need for sternotomy. Surgical outcomes are not affected by surgical approach. Simultaneous thoracic interventions for a coexistent pathology in patients with RSG may be considered. Further research of minimally invasive interventions for RSG resection is required.

Правобічні природжені діафрагмальні грижі – досвід лікування центру неонатальної хірургії

Congenital right-sided diaphragmatic hernias are a special form of diaphragmatic hernias. A relatively low frequency and features of anatomy, diagnosis clinical course, and survival characterize them. Objective: to analyze the results of treatment of right-sided diaphragmatic hernias in newborns. Materials and methods: a retrospective analysis of the medical records and autopsy protocols of 22 newborns with right-sided diaphragm defect, who were in the clinics of the State Institution «IPAG named after academician O.M. Lukyanova of the National Academy of Medical Sciences of Ukraine», was carried out for the last 37 years. Results: in 3 cases stillbirth was stated, in all live-born children (n=19) with right-sided СDH the defect was symptomatic. Moreover, in 84.2% (n=16) of them, symptoms of the disease occurred immediately after birth, in 10.5% (n=2) – from the first to 6 hours of life, in 5.3% (n=1) – after 24 hours, from birth. Signs of pulmonary hypertension were determined based on the difference between pre- and postductal peripheral blood saturation. Thus, in 62.5% (n=5) of operated children and in 63.6% (n=7) who died at the stages of stabilization, the difference in pre- and postductal saturation was more than 10%, whichindicated the presence of 100% pulmonary hypertension, and blood shunting from right to left, through fetal communications. The time of preoperative stabilization ranged from 1 to 23 days, on average 7.25 days. 8 children were operated. The surgical approach was right-sided subcostal laparotomy (n=5) or right-sided thoracotomy (n=2). In one case, there was a combined approach: right-sided laparotomy + right-sided thoracotomy. 5 children survived, 3 died. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. No conflict of interest was declared by the authors. Key words: congenital diaphragmatic hernia, right-sided, herniation of the liver, critical hypoplasia of the lungs, surgical correction, newborn baby.

Early surgical correction of mitral valve infection endocarditis in 16-year old female patient

The optimal time for surgery on the heart valves in patients with active infectious endocarditis (IE) is still controversial. It is a well known fact that cerebral, coronary or renal thromboembolism is the most common cause of death in patients with left-sided IE. Thromboembolism can develop before the appearance of clinical manifestations of the destruction of the valvular apparatus of the heart. Currently, early surgical intervention is considered as the most effective method of treatment of many forms of active left-sided IE. Early surgery involves performing surgical correction until the completion of a full antibiotics course. We present the clinical case of early surgical correction of the patient (A., 16 years) with mitral valve infectious endocarditis. The disease was acute, with recurrent embolisms to the right kidney with infarction and to the left clavicle with osteomyelitis. Surgical intervention was performed as a matter of urgency; surgical access right-sided anterolateral thoracotomy. The girl was operated on the 4th day of the hospitalization to our hospital. However, time of treatment was lost at the prehospital stage and rapid mitral valve destruction did not allow to repair the valve. Therefore, the mitral valve replacement was performed. The postoperative period was favorable. On the 3rd day after the operation, the girl was transferred to the cardiology department. On control ECHO after 3 years: myocardial contractile function is good, EF 65%, the function of the MV prosthesis is not impaired.

Functional Outcome of Right-sided Thoracotomy for Tuberculosis of the Dorsal Spine.

Introduction:In pathologies of the spine involving dorsal vertebrae, it is a routine practice to go for left-sided thoracotomy. It is so because in this approach, we encounter the aorta before reaching the concerned dorsal vertebra which is easy to handle as compared to the inferior vena cava on the right-sided approach. This is because the aorta is a structure with thick muscular wall. However, there are conditions which demand right-sided thoracotomy for better outcome such as idiopathic scoliosis and dorsal spine tuberculosis (TB). The selection of side of thoracotomy should be done on case-to-case basis.Study Design:This was a prospective study of 10-year duration.Purpose:The purpose of the study was to analyze whether it is more rational to do thoracotomy from the right side than left for dorsal spine TB.Materials and Methods:The study was performed on 102 dorsal Koch patients with neurological deficit who required surgical decompression. Magnetic resonance imaging of those patients was analyzed. Seventy-two patients had predominant right-sided lesion. Left and central types of predominant results were in 19 and 11 patients, respectively. Among these 102 patients, 82 were operated with right-sided thoracotomy, whereas 20 were operated for left-sided thoracotomy. Preoperative and postoperative kyphosis angle (K angle), average surgical time, mean blood loss, and visual analog scale (VAS) score were calculated. The SPSS 17 software was used for the statistical analysis.Results:Right thoracic approach turned out to be better approach than left in dorsal Koch spine. The average surgical time and mean blood loss were less in the right thoracotomy than left. Postoperative K angle and VAS were improved in the right thoracic approach as compared to left.Conclusion:Tubercular debris in the dorsal spine predominantly is on the right side, and right thoracotomy gives better results as there is better decompression of lesion.