Right-sided Thoracotomy Research Articles

Transaxillary left-sided minimally invasive approach for upper thoracic vertebral resection and reconstruction at T2–T3 levels: a case report

Surgical procedures of the upper thoracic spine are often challenging due to the anatomical topography of the thoracic spine. The most common approaches include the anterior supramanubrial, transmanubrial, and transsternal as well as the posterior approach with costotransversectomy. Recently, an infraaxillary right-sided thoracotomy was described for upper thoracic vertebral decompression and fusion at T2–T6 levels. In the current case, we report a transaxillary left-sided mini-thoracotomy for thoracic vertebral resection and reconstruction at T2–T3 levels. The incision enabled safe and uncomplicated surgery of the upper thoracic spine providing excellent exposure of the surgical site. Compared with the common incisions applied for surgery of the upper thoracic spine, surgical trauma is minimized without the need of sternotomy, division of the back muscles or resecting a rib. Moreover, anatomical critical structures such as the common carotid trunk, the jugular vein, or trachea are not encountered, hence increasing the safety of the procedure.

Ivor Lewis esophagectomy patients are particularly vulnerable to respiratory impairment - a comparison to major lung resection

Pulmonary complications and a poor clinical outcome are common in response to transthoracic esophagectomy, but their etiology is not well understood. Clinical observation suggests that patients undergoing pulmonary resection, a surgical intervention with similarities to the thoracic part of esophagectomy, fare much better, but this has not been investigated in detail. A retrospective single-center analysis of 181 consecutive patients after right-sided thoracotomy for either Ivor Lewis esophagectomy (n = 83) or major pulmonary resection (n = 98) was performed. An oxygenation index <300 mm Hg was used to indicate respiratory impairment. When starting surgery, respiratory impairment was seen more frequently in patients undergoing major pulmonary resection compared to esophagectomy patients (p = 0.009). On postoperative days one to ten, however, esophagectomy caused higher rates of respiratory impairment (p < 0.05) resulting in a higher cumulative incidence of postoperative respiratory impairment for patients after esophagectomy (p < 0.001). Accordingly, esophagectomy patients were characterized by longer ventilation times (p < 0.0001), intensive care unit and total postoperative hospital stays (both p < 0.0001). In conclusion, the postoperative clinical course including respiratory impairment after Ivor Lewis esophagectomy is significantly worse than that after major pulmonary resection. A detailed investigation of the underlying causes is required to improve the outcome of esophagectomy.

DOZ047.59: Development of operational tactics for esophageal atresia in the Republic of Tatarstan (Russia)

Abstract The Children's Republican Hospital of Kazan was opened in 1977 with the participation of prof. Rokytskyi, with rapid thoracic surgery development. In atresia of the esophagus, right-sided median thoracotomy, ligation of the tracheoesophageal fistula, Hayat esophagoplasty were performed. The duration of the operation was 2–3-4 h. With the installation of a pleural drainage for 2–3 weeks and a nasogastric tube for 1 month. When radical surgery was impossible, the upper and lower esophagostomas were applied, followed by coloesophagoplasty in 2–3 years. In 2003, the reconstruction and renovation of the surgical and resuscitation departments for neonates began. A new neonatal surgery team had been formed, studying in Ospedale Giannina Gaslini, Genova, Italy and St. Petersburg, Russia. As a result we introduced a single-row suture into the neonatal surgery for esophagoplasty. The duration of drainage was 7–10 days, the duration of the nasogastric tube was 2 weeks. The duration of hospital stay was reduced to 1–1.5 months. Another, ‘stormy’ development of neonatal surgery has undergone in 2013. The accumulated experience in the open surgery of the esophagus allowed us to begin to perform thoracoscopic esophagoplasty. Starting from 2013, more than 20 patients are operated annually with esophageal atresia of various forms. Mortality of about 3% in 5 years. We perform thoracoscopy, ligation and resection of tracheoesophageal fistula, end-to-end esophagoplasty with various diastasis. Esophageal anastomosis nodular extracarporal single row. The minimum weight of a patient with thoracoscopic esophagoplasty is 1200 g. The term draining of the pleural cavity is 3–5 days. A complicated group of patients consists of newborns with Long Gap. The final choice of surgical tactics is not yet decided. The primary and obligatory operation that is performed in LG is gastrostomy to feed the patient, with previous thoracoscopy and resection of the tracheoesophageal fistula with type 3 esophageal atresia. At the age of 2 weeks, gastroscopy and gastrography are performed in order to determine the diastasis between the esophagus. In conclusion, it is necessary to say the following. We consider thoracoscopic access for esophageal pathology as optimal, providing the patient with weighs more than 1200 g and without no concomitant pathology.

Extrapulmonary Intrapleural Hydatid Disease- A Case Report

Hydatidosis is a zoonotic disease caused by the tapeworm Echinococcus granulosus. It mostly involves liver and lungs whereas the unusual sites are spleen, kidney, peritoneal cavity, skin, muscles, heart, brain, vertebral column, ovaries, pancreas, gallbladder, thyroid gland, breast, and bones. Herein, we describe a unique case of intrapleural hydatid cyst which was solely confined to the pleural space without involvement of lung parenchyma and other associated structures. Despite the fact that Pakistan is an endemic country for hydatid disease, we could not identify any single documented case of intrapleural hydatid disease from Pakistan. The purpose of our case report is to promote awareness among fellow healthcare professionals about this rare variant of hydatid disease and to prevent any missed diagnosis and life-threatening complications. Hence, once the diagnosis was established, we performed a right-sided thoracotomy. Intraoperatively, the lung was collapsed due to the pressure effects of hydatid cysts. The hydatid cysts were evacuated completely from the pleural cavity and postoperatively the patient had an uneventful recovery and remained asymptomatic during all the follow-up visits. Conclusively, the hydatid disease may involve unusual sites such as the pleural space. A strong clinical suspicion, supportive radiological findings, and positive serological evidence play a critical role in the establishment of the diagnosis.

Tracheal localization of inflammatory myofibroblastic tumor in adults: A case report

Introduction. Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm. This disease, of unknown etiology, runs an unpredictable course. Its definitive diagnosis calls for a detailed histopathological analysis including immunohistochemistry. Microscopically, IMT is composed of myofibroblastic spindle and inflammatory cells in different proportions. It presents infrequently in adults with nonspecific symptomatology. The presence of IMT is described in every anatomical region but the tracheal one is especially uncommon. Case report. A 41- year-old female patient checked into our institution due to exacerbation of asthma-like symptoms such as shortness of breath, cough and exertion intolerance. She was originally treated as the asthmatic patient with the bronchodilator therapy with no success. Chest x-ray done during one of the outpatient follow-up appointments pointed to a suspected change in the tracheal distal part. After her admission to our institution, the following diagnostic procedures were performed: spirometry, chest computed tomography (CT) scan, chest magnetic resonance imaging (MRI) and bronchoscopy and the change in tracheal distal third was confirmed. Right-sided thoracotomy with mobilization of lung, tracheal resection and termino-terminal (T-T) anastomosis was undertaken. Subsequent histopathological analysis of surgically removed afflicted tracheal part of them trachea including immunohistochemistry enabled us to definitively of diagnose IMT. Four years after surgical resection, the patient showed no recidivism of illness. Conclusion. Definitive IMT diagnosis requires the detailed diagnostic tests, most importantly, an adequate histopathological analysis including immunohistochemistry. Complete surgical resection is the treatment of choice in case of IMT. Further monitoring of patients is necessary due to a risk of recurrence.

Features of course and surgical treatment of tonsillogenic neck phlegmons and mediastinitis

Background. The problem of adequate treatment for deep neck and mediastinal suppuration is one of the most difficult in surgery. It leads to such complications as mediastinitis, sepsis, arrosive bleeding, etc. The purpose was to investigate clinical, diagnostic and treatment features in patients with neck phlegmons and mediastinitis caused by pharyngeal suppurations. Materials and methods. The results of treatment of 31 patients with parapharyngeal phlegmons were presented. The average age of them was 48.24 ± 15.60 years, men were 18 (58 %), women — 13 (42 %). All persons suffered from severe endogenous intoxication. The time from the onset of the disease to surgery was about 4 days (from one to seven). Results. Most frequently, parapharyngeal suppuration was detected — in 16 (51.6 %) patients, then paratonsillar abscesses — in 11 (35.5 %), retropharyngeal suppurations — in 3 (9.7 %), and laryngeal cancer — in 1 (3.2 %). Lateral neck radiographs were performed in all patients preoperatively. Sensitivity of this investigation was 100 %. At the same time, chest X-ray to detect mediastinitis showed low rates of sensitivity — 60 %. Surgical approaches included extensive cervicotomy (often bilateral) and penetrative polydrainage of prevertebral space. Mediastinitis was found in 15 cases (48.4 %). It was enough to use blind drainage for upper posterior mediastinitis (11 cases, or 73.3 %). Right-sided thoracotomy was performed in one case of total posterior mediastinitis. Four patients died (13 %). Descending mediastinitis and sepsis were found in all lethal cases. Mortality rate in the group of patients with mediastinitis was 26.7 %. Conclusions. Neck phlegmons as a result of parapharyngeal suppuration are characterized by an aggressive course with significant endogenous intoxication and spread to the mediastinum in 48.4 % of cases with a lethality of 13 %. The lateral neck X-ray must be performed to all patients with suspicion of a deep neck phlegmon. In most cases (80 %), suppuration spreads from the parapharyngeal spaces to posterior mediastinum, which should be taken into account when opening purulent abscesses.

Prevalence and natural history of scoliosis and associated congenital vertebral anomalies in patients operated for esophageal atresia with or without tracheoesophageal fistula

BackgroundScoliosis has been reported after repair of esophageal atresia with or without tracheoesophageal fistula (EA-TEF). This study aims to investigate the prevalence and natural history of scoliosis and associated congenital vertebral anomalies in patients operated for EATEF. MethodsA retrospective review of patients operated for EA-TEF with radiological examination for the presence of scoliosis or associated spine congenital anomalies was done on 106 patients (ages 5–19 years). ResultsScoliosis was found in 53 patients (49%) for which 46 of these were in the thoracic region and 33 were right-thoracic curves. After a follow-up ranging from 5 to 14 years, four patients (3.7%) out of 106 were operated for scoliosis. Right-sided thoracotomy (RST) was the identifiable risk factor for scoliosis development; all patients with scoliosis had their EA repaired through RST. Congenital vertebral anomalies were found in 8 of those patients (7.5%). After a median follow-up of 6.5 years, no patients progressed enough to require operation. ConclusionScoliosis affects one of every two patients operated for EA; it may progress to the indication of surgery. RST was the identifiable risk factor for scoliosis development.

Esophageal replacement by gastric transposition: A single surgeon's experience from a tertiary pediatric surgical center

BackgroundMany pediatric surgeons have limited experience of esophageal replacement. This study reports outcomes of esophageal replacement by gastric transposition performed by a single UK-based pediatric surgeon. MethodsConsecutive patients were identified who underwent esophageal replacement by gastric transposition over a 28 year period. Clinical and demographic data were collected. Weight-for-age Z-scores were calculated for esophageal atresia patients. ResultsNineteen patients were identified. Indication in the majority was long-gap esophageal atresia (n = 17; 10 with tracheoesophageal fistula). At surgery, median age was 8.5 months (range 2–55); median weight was 7.4 kg (range 4.0–17.4 kg). A right-sided thoracotomy or transhiatal approach was used. Median postoperative length of stay was 17.5 days (range 7–130); median intensive care stay was three days (range 1–63). There were no deaths. Anastomotic leak rate at 30 days was 10.5% (n = 2). One patient required early stricture dilatation. Median weight-for-age Z-score increased from −2.17 at one year of age to −1.86, −1.70 and −1.93 at 5, 10 and 15 years. ConclusionsEsophageal replacement by gastric transposition offers a potentially life-changing treatment; however, it is associated with significant morbidity. The majority of patients eventually achieve full oral feeding and maintenance of weight gain trajectory. A right-sided approach to the esophagus is feasible. Type of StudyTreatment Study. Level of EvidenceIV.

Intrathoracic (mediastinal) goiter. A clinical case

Using a clinical case as the example the article sheds light on the issues of diagnosis and surgical treatment of intrathoracic goiter. A comprehensive approach to the problem which allows the most radical implementation of surgical treatment and involves thoracic and endocrine surgeons is taken into consideration. The intrathoracic goiter, which constitutes 16-37% of all cases of mediastinal tumors, can be removed by thoracic surgeons with the neck part of the thyroid gland left without surgical attention, which leads to reoperations. At the same time the intrathoracic part of the thyroid gland, occurring in 0.1-0.5% of cases among all the operated goiters, remains unnoticed by endocrine surgeons. In our case the diagnosis of intrathoracic goiter was proved in 56-year-old woman by the multispiral CT after the separated node of thyroid tissue was suspected by ultrasound examination and palpation. It was decided to carry out a joint operation. Under the conditions of the thoracic center the patient underwent cervicotomy, right-sided mid thoracotomy and extrafascial thyroidectomy. The neck part of the thyroid gland was removed with extrafascial standard exposure according to Kocher. The thoracic part was removed with thoracotomy exposure. If the multinodular goiter is localized in posterior mediastinum the transverse size of aperture should be considered for the choice of surgery tactic: in cases the latter is

Surgical access via right thoracotomy facilitates tricuspid valve surgery in sheep.

In quadrupeds, the three-dimensional orientation of the heart with respect to the thorax is fundamentally different from that in humans. In this study, we assessed the best surgical approach to the tricuspid valve in sheep. Firstly, different surgical access sites to the tricuspid valve were tested in sheep cadavers, the anatomy was analyzed, and the optimal surgical approach to the tricuspid valve was determined. Secondly - along with cardiopulmonary bypass and cardioplegic arrest -the chosen approach was tested in six adult sheep in vivo. Anatomical analyses revealed that a left thoracotomy provided optimal access to the aorta and left heart. However, visualization of the right heart was significantly impaired. In contrast, a right thoracotomy provided good access to the right heart, but the ascending aorta was difficult to approach. Therefore, in the in vivo studies, arterial cannulation was performed through a carotid (n = 4) or femoral (n = 2) artery. In conclusion, a right-sided thoracotomy allows good visualization of all components of the tricuspid valve complex in sheep, but not of the ascending aorta. Consequently, peripheral vessels are preferred for arterial cannulation. This work may stimulate the investigation of pathomechanisms and/or novel treatment options for tricuspid valve pathologies.

Right Posterior Thoracotomy for Open-Heart Surgery in a Rare Morphology

The closure of atrial septal defects through right-sided limited posterior thoracotomy has been well established in selected subsets. We present a case of large ostium secundum atrial septal defect, pulmonary valvar stenosis, absent right superior vena cava, and isolated left superior vena cava draining to right atrium via coronary sinus. The child successfully underwent total correction through limited posterior thoracotomy with necessary modifications of intraoperative steps.

A clinical prediction model for prolonged air leak after pulmonary resection

ObjectiveProlonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables. MethodsPatients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed. ResultsA total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk. ConclusionsUsing readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management.

Repair of oesophageal atresia with tracheo-oesophageal fistula associated with dextrocardia through right-sided thoracotomy approach

Right thoracotomy for oesophageal atresia (OA) with dextrocardia is technically challenging due to the heart being in the operative field, and also due to the possibility of right-sided aortic arch. We report a neonate with longgap OA with tracheo-oesophageal fistula (TOF), dextrocardia, and left-sided aortic arch who was successfully operated by using right thoracotomy. On the basis of our review of the literature and our experience from this case, we found that conventional right thoracotomy is appropriate for OA+ TOF associated with dextrocardia and left aortic arch, and left thoracotomy in dextrocardia and right aortic arch. Keywords: dextrocardia, oesophageal atresia, right thoracotomy, tracheo esophageal fistula

The Warden procedure can be successfully performed using minimally invasive cardiac surgery without aortic clamping.

Currently, minimally invasive cardiac surgery has found widespread use even in congenital heart surgery. The number of defects, which can be corrected through a small incision or totally endoscopic, is on the rise. Nowadays, surgeons can repair atrial septal defect, ventricular septal defect, patent ductus arteriosus and other congenital heart defects using minimally invasive techniques. In this paper, we report 21 cases of successful repair of supracardiac partial anomalous right upper and middle pulmonary venous connection, using the Warden procedure. It was performed in children through the right-sided midaxillary thoracotomy with direct cardiopulmonary bypass cannulation and induction of ventricular fibrillation. There were no operative or early postoperative deaths or complications. All patients were in sinus rhythm at discharge. According to echocardiography, there were no cases of early SVC or pulmonary veins narrowing. The Warden procedure can be performed safely and efficiently using the minimally invasive cardiac surgery.

Thoracoscopic Approach in Recurrent Tracheoesophageal Fistula

Abstract Introduction: Recurrent fistulization after tracheoesophageal fistula (TEF) repair can be a complication of difficult management. There are few data on thoracoscopic reintervention.1,2 The authors present a video of a thoracoscopic approach in a recurrent fistula after TEF repair by thoracotomy. Material and Methods: A child with 20 months of life was found with a recurrent fistula by bronchoscopy. The patient had a history of recurrent respiratory symptoms after a surgical correction of esophageal atresia with TEF by thoracotomy. A right-sided thoracotomy was performed; three trocars were used (two 5 mm and one 3 mm). Right upper lobe adhesions from a previous surgery were divided with electrocautery. The azygos vein was identified and preserved. The TEF was identified just above the azygos vein, dissected, and isolated; two titanium clips were applied and the fistula was then divided. The clips were reinforced with endoloops®. A prolene® mesh was interposed between the trachea and the esophagus...

Single-staged surgical approach in congenital diaphragmatic hernia associated with esophageal atresia

BackgroundThe coexistence of congenital diaphragmatic hernia (CDH) with esophageal atresia (EA) has only been reported occasionally in literature. Series of patients from a single institution with comparison of different postnatal therapeutic approaches have not been reported. We describe our management in this unique cohort of patients and discuss the procedures that can lead to successful outcomes in this association of congenital anomalies. MethodsThe surgical approaches and outcome of six neonates with CDH associated with EA and distal tracheo-esophageal fistula (TEF) are discussed. ResultsFive newborns were treated surgically, while one patient with trisomy 18 only received palliative treatment. In four patients TEF was ligated during laparotomy for CDH repair. Secondary surgery was performed for correction of EA via thoracotomy after 4–6weeks (primary anastomosis in two patients, Foker’s-technique in one patient, one patient deceased prior to secondary surgery). All three surviving patients required fundoplication due to severe gastro-esophageal reflux during the first year of life. Two patients also required dilatation for anastomotic stricture. In one preterm infant correction of both malformations was accomplished during one surgical intervention. The herniated organs were eventrated and temporarily placed into a silastic bag to allow a mediastinal shift to the left. Thus a continuous ventilation of the right lung with minimal compression and sufficient oxygenation was possible during esophageal repair via a right-sided thoracotomy and extrapleural approach. No further surgery was required so far. ConclusionsDefinitive surgical correction in newborns with CDH and EA was so far accomplished with multiple surgical interventions. Ligation of TEF via an abdominal approach with repair of CDH followed by delayed repair of EA is prone to stenosis and gastro-esophageal reflux due to loss of esophageal length. With a new combination of established surgical methods a single-staged correction of both malformations is possible. This new approach might help to preserve sufficient length of esophagus to accomplish primary anastomosis without tension and therefore avoid long-term morbidity and repetitive surgeries.

Mini-invasive technologies in complex treatment of esophagus cancer

It was evaluated mini-invasive endovideosurgical technologies using in complex treatment of esophagus cancer. The investigation included 28 patients with thoracic esophagus cancer. Age of patients operated in terms from April 2012 to December 2013 was from 42 to 74 years (mean 61.7 ± 8.7 years). Only surgical treatment was used in 10 patients. Neoadjuvant chemotherapy and radiotherapy were performed in 18 patients. Hybrid mini-invasive esophagectomy (laparoscopic stomach mobilization and right-side thoracotomy) were used in 14 cases. The frequency of postoperative complications was 35.5%. Mini-invasive endovideosurgical esophagectomy was done in 14 patients. The frequency of postoperative complications was 57.1%. There were not deaths. Our experience demonstrates good results of mini-invasive technologies using in treatment of patients with esophagus cancer. Endovideosurgical methods permit to perform adequate volume of surgery in case of oncological diseases.

Minimally invasive access for central extracorporeal life support: how we do it.

Central extracorporeal life support (ECLS) is an effective treatment method of cardiogenic shock patients with or without lung failure. However, complications like infection and bleeding are common. The classical implantation approach requires full sternotomy, mobilization of the heart, with the well-known risks of bleeding and mediastinal infections. We present our minimally invasive technique for central ECLS through a nonsternotomy incision. Minimized right-sided thoracotomy is performed. Flexible arterial and venous cannulas are tunneled toward the right thoracotomy incision through the eighth intercostal space. A sewing ring is secured to the right atrium and a tube graft is anastomosed to the ascending aorta. Following full-dose heparinization, the arterial cannula is inserted with the tip into the vascular graft of the ascending aorta and the venous cannula via the ring into the right atrium. After meticulous deairing, the central ECLS is set at full flow.

Cancer of the oesophagus and gastroesophageal junction - a difficult clinical problem.

IntroductionCancer located in the oesophagus and gastroesophageal junction is a complex clinical problem and the results of its treatment still remain unsatisfactory. The objective of the study was the clinical analysis of a group of patients with cancer of the oesophagus or gastroesophageal junction, who received combined medical and surgical treatment.Material and methodsThe analysis was performed on a group of 128 patients with the diagnosis of oesophageal cancer or cancer of the gastroesophageal junction. Analysis of medical records and follow-up examinations were used in the research procedure.ResultsFrom among 128 patients with a diagnosis of oesophageal or gastroesophageal junction cancer, 50 (38.5%) received surgical resections. The surgery most frequently performed (n = 15) was sub-total oesophageal resection according to Akiyama procedure by right-sided thoracotomy (oesophageal anastomosis in the neck). The largest group were patients (n = 26) with stage T3N1M0 of advancement of the disease. In all cases of cancer located in the lower third of the oesophagus, an adenocarcinoma pattern was diagnosed in the histopathological examination, whereas in the case of cancers located in the middle third and upper third of the thoracic oesophagus a carcinoma planoepitheliale pattern was seen. Anastomotic leaks occurred in seven patients (14%). Six patients died during the post-operative period (12%). The mean survival time in the group of analysed patients was two years.ConclusionsCancer of the oesophagus or gastroesophageal junction is associated with low resectability, high risk of complications after surgery, and poor oncologic outcome. It is necessary to seek new methods of treatment.

Repair of Tracheal Aspergillosis Perforation Causing Tension Pneumothorax

Tracheobronchial aspergillosis is a rare entity mainly observed in immune-compromised patients or those who have undergone transplantation. It may cause airway ulcerations or bleeding. We report the case ofa 17-year-old patient receiving chemotherapy foracute lymphoblastic leukemia who presented withright-sided tension pneumothorax. Chest tube drainage revealed a massive air leak without reexpansion of the lung, and bronchoscopy showed a15-× 15-mm defect of the distal trachea related to aspergillosis infection. The defect was closed by an intrathoracic transposition of a pedicled latissimus dorsi muscle flap, which was sutured into the debrided defect followed by temporary endotracheal stenting and antifungal medication.