Thoracic Incision Research Articles

Esophagectomies With Thoracic Incisions Carry Increased Pulmonary Morbidity

Thoracic incisions are not required for all esophagectomies and may increase pulmonary morbidity. To compare the pulmonary and overall morbidity of esophagectomies with and without thoracic incisions. Observational study. Hospitals participating in the National Surgical Quality Improvement Project. Patients without metastatic cancer undergoing nonemergency total esophagectomies with reconstruction from 2005 through 2010. Patients who underwent transhiatal esophagectomy (THE) were compared with a THORACIC group (Ivor Lewis and McKeown techniques). Pulmonary and overall morbidity, infection, and thromboembolic complications. Of 1568 patients, 717 (45.7%) underwent THE, and 851 (54.3%) were in the THORACIC group (Ivor Lewis technique in 487 [31.1%] and McKeown technique in 364 [23.2%]). The population was 80.5% male, with a mean age of 62.9 years. Patients undergoing THE were older (P = .02). Diabetes mellitus was less common in the THORACIC group (11.2% vs 15.9% for THE; P = .02), and cancer was more common (91.0% vs 87.0%; P = .01). Morbidity was 49.2% and mortality was 3.3%, without differences between groups. The mean length of stay was 1.6 days shorter (P = .009) in the THE group. Multivariable analysis showed that thoracic incisions increased rates of pneumonia (odds ratio [OR], 1.47; P = .007), ventilator dependence (OR, 1.35; P = .04), and septic shock (OR, 1.86; P = .001) but not mortality. Compared with the Ivor Lewis technique, the McKeown technique worsened the odds of superficial wound infections (OR, 1.71; P = .02) but not septic shock (OR, 0.84; P = .47). Esophagectomies have an acceptable mortality rate but a significant morbidity rate. We demonstrated that rates of pneumonia, ventilator dependence, and septic shock are increased with the use of thoracic incision. Avoiding thoracic incisions may therefore decrease the risk of pulmonary morbidity and septic shock.

Thoracoscopic enucleation of esophageal leiomyoma in prone position and single lumen endotracheal intubation

Esophageal leiomyomas are the most common benign tumors of the esophagus. Surgical enucleation is warranted for symptomatic patients. Thoracoscopic enucleation is the preferable approach for being less invasive by avoiding the discomfort and complications associated to larger thoracic incisions. The purpose of this study was to review our experience with enucleation of esophageal leiomyoma using a prone-position thoracoscopy technique. Between January 2009 and July 2012, ten patients underwent resection of esophageal leiomyoma by thoracoscopy approach in prone position. Indications for surgical treatment were symptomatic tumors (dysphagia). All patients were followed postoperatively for at least 3 months with contrast x-ray of the esophagus. After single-lumen endotracheal intubation (nonselective intubation) in supine, patients were placed in prone position. Pneumothorax was kept at 6 to 8 mmHg using CO2 insufflation. A myotomy was performed over the tumor using hook cautery carefully protecting the mucosa from injuries. The myotomy was closed with continuous sutures. The procedures were completed in the prone position in all cases, without any conversion. Mean operative time was 89.2 ± 28.7 minutes. Bleeding was negligible, and there were no intraoperative or postoperative complications. No intensive care unit support was needed for any patient. Chest x-ray in the first postoperative day showed no significant changes in any patient. The mean hospital stay was 3.2 days. Contrast x-ray of the esophagus was normal in all patients at 3 months postoperatively. Thoracoscopic enucleation of esophageal leiomyoma is a feasible, simple, and safe procedure. Thoracoscopy in the prone position with CO2 insufflation allows the use of usual technique of intubation and also provides optimal operative field. The advantages of the thoracoscopic approach are less postoperative discomfort and lower risk of complications from open thoracotomy (especially pulmonary).

Atypical or typical adrenocorticotropic hormone-producing pulmonary carcinoids and the usefulness of 11C-5-hydroxytryptophan positron emission tomography: two case reports

IntroductionPulmonary carcinoids associated with ectopic adrenocorticotropic hormone secretion have a good prognosis if histological examination shows typical pulmonary carcinoid and low proliferation, whereas a poor outcome is linked to atypical pulmonary carcinoid and high proliferation. Here we describe the diagnostic challenges to find the tumor in Cushing’s syndrome secondary to ectopic adrenocorticotropic hormone secretion in two cases with an atypical and a typical pulmonary carcinoid, respectively.Case presentationA 63-year-old Caucasian woman presented with aggressive clinical features related to Cushing’s syndrome, having very high levels of urinary cortisol and circulating adrenocorticotropic hormone and cortisol. Magnetic resonance imaging showed no pituitary tumor, and bilateral inferior petrosal sinus sampling revealed no central peripheral ratio of adrenocorticotropic hormone. Computed tomography and 111Indium-pentetreoide somatostatin receptor scintigraphy could not visualize any ectopic tumor. The patient was referred for an 11C-5-hydroxytryptophan positron emission tomography, and a small 8mm nodule in her left lung was found. The tumor was removed via a lateral thoracic incision and wedge excision. The histological examination showed an atypical carcinoid with Ki-67 index of 9 to 10%, and an additional lobectomy was performed.The second patient, a 22-year-old Caucasian man, also presented with aggressive Cushing’s syndrome, with very high urinary cortisol levels and increased circulating cortisol as well as adrenocorticotropic hormone levels. A magnetic resonance imaging scan of the pituitary showed no tumor, whereas a 12×9×14mm tumor was detected in the right lung on the primary computed tomography scan and no further investigation was performed. The tumor was removed via a lateral thoracic incision and wedge excision. A typical carcinoid with Ki-67 index of 1 to 2% was found and no further surgery was performed.After surgical removal, the biochemical disturbances resolved and significant clinical improvement were achieved in both patients after 24 months of follow up.ConclusionsDiagnostic evaluation time is limited due to the aggressive course in ectopic adrenocorticotropic hormone-dependent Cushing’s syndrome. We suggest that 11C-5-hydroxytryptophan positron emission tomography could be considered early as a secondary diagnostic tool when primary computed tomography and/or magnetic resonance imaging scans fail to show any tumor.

Transoral endoscopic surgery versus conventional thoracoscopic surgery for thoracic intervention: safety and efficacy in a canine survival model

Transoral endoscopic surgery has been shown to be feasible and safe in both humans and animal models. The purpose of this study was to evaluate the safety and efficacy of transoral and conventional thoracoscopy for thoracic exploration, surgical lung biopsy, and pericardial window creation. The animals (n = 20) were randomly assigned to the transoral endoscopic approach group (n = 10) or conventional thoracoscopic approach group (n = 10). Transoral thoracoscopy was performed with a flexible bronchoscope via an incision over the vestibulum oris. In conventional thoracoscopy, access to the thoracic cavity was obtained through a thoracic incision. Surgical outcomes (body weight, operating time, operative complications, and time to resumption of normal diet), physiologic parameters (respiratory rate, body temperature), inflammatory parameters [white blood cell (WBC) counts and C-reactive protein (CRP)], and pulmonary parameters (arterial blood gases) were compared for both procedures. The surgical lung biopsy and pericardial window creation were successfully performed in all animals except one animal in the transoral group. There was no significant difference in operating times between the groups. The increase in WBC in the transoral thoracoscopy group was significantly smaller on postoperative day 1 than in the conventional thoracoscopy group (p = 0.0029). The transoral group had an earlier return to preoperative body temperature (p = 0.041) and respiratory rate (p = 0.045) on day 7. With respect to pulmonary parameters, there was no significant difference in blood pH, pCO2, or PaCO2 between the transoral and transthoracic groups. All animals survived without complications 14 days after surgery. This study demonstrated that the transoral approach was comparable to conventional thoracoscopic surgery for lung biopsy and pericardial window creation in terms of safety and efficacy.

Five Hundred Cases of Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Predictors of Success and Safety

Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures. Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation. Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002). Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

LOW-INTENSITY LASER THERAPY AND LED (LIGHT EMITTING DIODE) THERAPY IN MECHANICAL RESISTANCE OF RATTUS NORVEGICUS CHEST INSCISION WITH IMPLANT OF STEEL WIRE FOR STERNAL SUTURE

INTRODUCTION: Low-intensity laser (LILT) and LED therapy are indicated in repairing surgical incisions, which occur in cardiac surgery. One major concern in this case is the presence of metallic wire used for sternal sutures, its temperature may rise while using a laser or LED. This study aimed to analyze the tensiometric properties of the skin tissue with longitudinal incision and metallic wire implant used for sternal suture irradiated with LILT and LED. METHODS: Twenty-five subjects (Rattus norvegicus) were submitted to thoracic incision with implantation of metallic wire, and subsequently divided into five groups: GI (control group); GII (laser group 6J/cm2); GIII (laser group 10J/cm2); GIV (LED group 6 J/cm2); and GV (LED 10J/cm2). Photobiomodulation was performed on a daily basis for eight consecutive days and the local temperature was measured before and after phototherapy. After euthanasia the tissues were subjected to tensiometric and histological analysis. RESULTS: All irradiated groups showed increase in break strength (p = 0.009), and decrease in tissue deformation strength compared with the control group (p = 0.03). CONCLUSION: Both LILT and LED can promote wound healing at the tested doses with increased tissue resistance, although its elasticity is reduced. The imprecision of the assessing instruments precluded an accurate measurement of a possible local tissue heating post irradiation and future studies are need to elucidate this effect.

Robotic total endoscopic double-vessel coronary artery bypass grafting—state of procedure development

Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 10 years. With increasing experience and technological improvement, double-vessel TECAB has become feasible. The aim of the present study was to compare the current outcomes of single- and double-vessel TECAB. Between 2001 and 2011, 484 patients underwent TECAB by 4 surgeons at 2 institutions. The median patient age was 60 years (range, 31-90), and the median European System for Cardiac Operative Risk Evaluation was 2 (range, 0-13). Single-vessel (n = 334) and double-vessel (n = 150) procedures were performed using the da Vinci, da Vinci S, and da Vinci Si robotic systems. Compared with the single-vessel procedure, double-vessel TECAB required a longer operative time (median, 375 minutes; range, 168-795; vs median, 240; range, 112-605; P < .001) and had an increased conversion rate to a larger thoracic incision (31/150 [20.7%] vs 31/334 [9.3%]; P < .001). The median ventilation time was 10 hours (range, 0-288) for double-vessel versus 8 hours (range, 0-278) for single-vessel procedures (P = .006). The hospital stay was comparable, with 6 days (range, 2-27) for double-vessel TECAB and 6 days (range, 2-33) for single-vessel TECAB (P = .794). Perioperative mortality was 0.3% (1/334) with single-vessel TECAB and 2.0% (3/150) with double-vessel TECAB (P = .090). Freedom from major adverse cardiac and cerebral events at 5 years was similar after double- and single-vessel TECAB (73.5% vs 83.1%, P = .150). The 5-year survival was 95.8% and 93.9% (P = .708). Double-vessel TECAB appears feasible and reproducible. The operative times were longer and the conversion rates to a larger thoracic incision were greater than with single-vessel TECAB. Also, the postoperative ventilation time was longer. Other perioperative morbidity and mortality and the recovery time and long-term clinical outcomes, however, were comparable.

Characteristics of lymphatic metastasis and surgical approach of adenocarcinoma of the esophagogastric junction

To investigate the characteristics of lymphatic metastasis in different types of adenocarcinoma of the esophagogastric junction (AEG) and provide guidance for surgical approach adoption. Clinical data of 228 patients with AEG undergoing surgery were analyzed retrospectively. According to Siewert classification, there were 9 cases of type I (3.9%) who all underwent left thoracoabdominal approach procedures. A total of 121 patients belonged to type II (53.1%), of whom 12 underwent left transthoracic approach, 48 left thoracoabdominal approach, and 61 transabdominal approach. Ninety-eight patients belonged to type III (43%), of whom 22 underwent left thoracoabdominal approach procedures and 76 transabdominal. The pattern of lymph node metastasis was analyzed and the association between surgical approach and oncological clearance was examined. The resection margin was positive in 20(8.8%) patients, including 10 with type II (8.3%) and 10 with type III (10.2%), and the difference was not statistically significant (P>0.05). The rate of positive resection margin was 12.4%(17/137) in the transabdominal group and 16.7%(2/12) in the left transthoracic group, both significantly higher than the left thoracoabdominal group (1.1%, 1/88) (both P<0.05). Lymph node metastasis was found in 159(69.7%) patients. The metastasis was found in 4 of 9 patients with type I cancer and two were thoracic metastasis, no metastasis was found in the upper mediastinum. For type II cancer, the rate of lymph node metastasis was 66.9%(81/121), including thoracic metastasis ( n=32, 26.4%) and abdominal metastasis (n=81, 66.9%). For type III cancer, the rate of lymph node metastasis was 66.9%(81/121), including thoracic metastasis (n=15, 15.3%) and abdominal metastasis (n=69, 70.4%). For type I AEG, left thoracoabdominal approach should be used because the pattern of lymph node metastasis is similar to that of the distal esophageal carcinoma. For type II , left thoracoabdominal approach should be used to ensure adequate resection of the tumor and clearance of lymph node in the lower esophagus and upper mediastinum because of high rate of intrathoracic lymph node metastasis. For type III cancer, transabdominal incision offers better benefit with less impact on respiratory function. However, thoracic incision should be used to ensure adequate clearance for tumors of larger size and significant external invasion.

Cervical Video-Assisted Thoracoscopic Surgery Using a Flexible Endoscope for Bilateral Thoracoscopy

Video-assisted thoracoscopic surgery (VATS) has become the standard of care for pleural evaluation, drainage, and pleurodesis. The major limitations to standard VATS techniques include intercostal pain and the unilateral nature of the procedure. We report on a cervical VATS approach for bilateral thoracoscopy, pleural biopsy, and talc pleurodesis using a flexible video endoscope without any intercostal incision. A 64-year old male with peritoneal carcinomatosis was noted to have significant bilateral pleural effusions. A cervical video-assisted thoracoscopic surgery (C-VATS) procedure was performed through a 2-cm cervical incision using a sterile flexible gastroscope. Bilateral thoracoscopy, pleural drainage, pleural biopsies, lung biopsy, and talc pleurodesis were performed. No thoracic intercostal incisions were performed. Total operative time was 48 minutes. The procedure was successful and the recovery was uneventful. The patient was discharged 4 days after the procedure. C-VATS is an extremely minimally invasive procedure. It avoids intercostal incisions and allows for bilateral pleural procedures through a single small cervical incision.

Distinct activation of tumor necrosis factor-α and interleukin-6 in the spinal cord after surgical incision in rats

In a previous study, we showed that a deep thoracic incision induces the segmental upregulation of interleukin-1β (IL-1β) in the spinal cord. However, whether the cytokines tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) are also activated in response to surgical incision remains to be determined. The present study aimed to investigate the expression pattern of TNF-α and IL-6 in the spinal cord following a deep thoracic incision. After surgical incision, the mRNA levels of TNF-α and IL-6 in the thoracic spinal cord were transiently upregulated as determined by real-time polymerase chain reaction (PCR) assay. However, the activation of IL-6 was detected at 1 h postoperatively, which was earlier compared to that of TNF-α, observed at 6 h postoperatively. The activated TNF-α was mainly localized in the neurons, but not in microglia or astrocytes as determined by immunohistochemistry and confocal microscopy. However, the increased IL-6-immunoreactivity was mainly expressed in blood vessels. The differential upregulation of TNF-α and IL-6 induced by incision suggests that the proinflammatory cytokines may play different roles in the development of surgical pain.

Traitement des anévrismes de la crosse aortique : pour un nouveau modèle « translationnel » entre médecine et technologie

Until quite recently, aneurismal or dissecting lesions of the aortic arch were untreatable, leaving patients exposed to a risk of fatal rupture. Indeed, aortic arch surgery concentrates most of the difficulties encountered during arterial repair. Access to the lesion takes one or more invasive thoracic incisions during open repair, or complex and embologenic navigation during endovascular repair. The proximity of the heart means that the affected segment can only be isolated by means of cardiac or circulatory arrest, or bypass, while flow interruption through the supra-aortic trunks carries a risk of cerebral ischemia within a matter of minutes. In addition, the geometry and dynamics of the aortic arch subject synthetic devices to major stresses both during and after repair. Various technologies have been harnessed in an attempt to increase the proportion of patients amenable to therapy, such as hemodynamic protection by cardiopulmonary or extra-anatomic bypass, tissue preservation technologies, and endovascular approaches. Progress remains slow, however, owing to the lack of a suitable medico-economic model for this relatively infrequent disorder. These lesions therefore represent an excellent model for developing new collaborative approaches between medical and technological research.

Endovascular Therapy for Thoracic Aortic Aneurysms: State of the Art in 2012

Conventional surgery for thoracic aortic pathology involves replacing the affected segment of aorta with an interposition graft and often requires the use of extracorporeal circulatory support with or without deep hypothermic circulatory arrest. Although operative results have improved consistently over 60years, patients with extensive aneurysms face a considerable risk with conventional surgery, particularly when burdened with multiple comorbidities. Thoracic endovascular aortic repair (TEVAR) was first performed in 1994 and has become a well-established alternative therapy for many thoracic aortic pathologies. TEVAR is most frequently performed through a small groin incision to access the common femoral artery. Wires and catheters are used to deliver and deploy the stent graft in the thoracic aorta under fluoroscopic control. Occasionally, TEVAR is performed as part of a complex hybrid procedure including one stage of conventional open surgery that may utilize a thoracic incision and cardiopulmonary bypass support. The less invasive nature of TEVAR offers the potential for lower mortality and peri-procedural morbidity. Although long-term results of TEVAR are still being gathered, mid-term results are excellent and most late vascular complications can be treated with additional transcatheter procedures. Recent development of fenestrated and branched stent grafts is expanding the application of endovascular therapies to complex aortic pathologies involving the thoracoabdominal aorta and aortic arch. Although conventional techniques continue to be the gold standard for treatment of ascending aortic pathology, recent reports have proven TEVAR to be a viable alternative in specific situations. Design improvements continue to expand the indications for TEVAR, and technological advancements in the field of imaging facilitate safer and more accurate planning, delivery, and assessment of patients with thoracic aortic aneurysms. Hybrid operating rooms provide the optimal environment with state of the art imaging technology for the cardiovascular team to perform TEVAR or alternative hybrid procedures.

Early diagnosis and treatment of combined thoracoabdominal injury

Objective To summarize the experience in early diagnosis and emergency treatment for combined thoracoabdominal injury (CTI). Methods Clinical data of 58 cases of CTI admitted to our hospital from June 2001 to August 2009 were analyzed retrospectively.All the patients were treated by closed drainage of thoracic cavity,of which 12 cases were treated with thoracotomy,31 with laparotomy,seven with thoracic and abdominal incisions and three with combined thoracoabdominal incision.Internal fixation for long limb bones was performed in 27 cases,spinal laminectomy and pedicle screw fixation in five and amputation in one. Results After operation,six cases were found to have adult respiratory distress syndrome (ARDS) and 12 cases were complicated with multiple organ dysfunction syndrome (MODS).Fifty-three cases were cured and five died. Conclusions CTI based multiple injuries are severe and complicated.CT scan in the early stage plays a significant role in the diagnosis of CTI and closed drainage of thoracic cavity is an important assurance of the security of abdominal operation.Early diagnosis,correct choice of operation procedures and reasonable handling order of injured organs can improve the successful rescue rate for multiple injury patients. Key words: Multiple trauma; First aid; Combined thoracoabdominal injury

Robotic Totally Endoscopic Multivessel Coronary Artery Bypass Grafting Procedure Development, Challenges, Results

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.

Impact of the Surgical Technique on Pulmonary Morbidity After Esophagectomy

Pulmonary complications occur frequently after esophagectomy. Although multifactorial, these complications could be influenced by surgical technique. We sought to compare the respiratory complications of patients undergoing esophagectomy through different approaches, and identify technical risk factors. We conducted a retrospective analysis of consecutive esophagectomies performed at 2 institutions from January 2002 to January 2009. Primary outcome measures included postoperative ventilatory requirements, pneumonia, effusion requiring intervention, length of stay, and mortality. A total of 220 esophagectomies were performed through 6 different approaches: 79 minimally invasive (MIE) with neck anastomosis, 20 MIE with chest anastomosis, 37 transhiatal, 33 McKeown, 36 Ivor Lewis, and 15 left thoracoabdominal. Patients who underwent MIE were more likely to be extubated in the operating room (p<0.01) and had fewer pleural effusions (p<0.01). A thoracotomy was associated with a higher incidence of tracheostomy (p=0.02) and pleural effusions (p=0.02). Neck anastomoses were negatively associated with early extubation (p=0.04) and predicted recurrent laryngeal nerve injury (p=0.04), but were not associated with pneumonia or other pulmonary complications. Multivariate analysis showed that pneumonia was independently associated with advancing age (p=0.02), lack of a pyloric drainage procedure (p=0.03), and less significantly with MIE (p=0.06, fewer events). Surgical approach was not a significant predictor of length of stay or mortality. Patients undergoing MIE are less likely to remain intubated. Omission of a pyloric drainage procedure or performance of thoracic or neck incisions appear to be important determinants of respiratory complications. Technical aspects of the procedure in addition to the surgical approach influence important respiratory outcomes.

A Pilot Study of Laparoscopic Gastric Pull-Up by Using the Natural Orifice Translumenal Endoscopic Surgery Technique: A Novel Procedure for Treating Long-Gap Esophageal Atresia (Type A)

This study aimed to develop a novel procedure for treating long-gap pure esophageal atresia. This procedure, which entails the combined use of laparoscopy and natural orifice translumenal endoscopic surgery (NOTES), would enable primary repair without cervical and thoracic incisions and prevent postoperative gastroesophageal reflux disease (GERD). Nonsurvival experiments were conducted in 9 pigs to study the technical feasibility. The procedure comprised the following: (1) creation of the disease model by laparoscopic resection of the lower esophagus; (2) laparoscopic fundoplication, complete mobilization of the stomach, and enlargement of the esophageal hiatus; (3) formation of a peroral transesophageal entry site into either the postmediastinum or the right thoracic cavity followed by fashioning a tunnel to the peritoneal cavity; (4) gastric pull-up by using both laparoscopy and NOTES; (5) esophagoesophageal anastomosis using BraceBar™, a prototype of the double T-bar suturing device (Olympus Medical Systems Co., Tokyo, Japan). Laparoscopic procedures were performed without complications. The postmediastinal tunnel was successfully created three times with a complication of pleural injury. However, gastric pull-up via this route could not be completed due to porcine anatomical reasons. Gastric pull-up through the right thoracic route was achieved five times in six attempts. Two disorientations and a hemorrhagic death occurred during the procedures. This study showed that combined use of laparoscopy and NOTES enabled gastric pull-up without cervical and thoracic incisions. Our method has the potential of lowering the incidence of GERD and enabling primary repair of this disease.

Pharyngolaryngoesophagectomy in a patient with an aberrant right subclavian artery: Report of a case

We report a case of carcinoma of the hypopharynx and cervical esophagus in a patient with an aberrant right subclavian artery. Barium esophagography, endoscopy, and computed tomography showed a resectable tumor in the hypopharynx and cervical esophagus, coexistent with an aberrant right subclavian artery. We performed pharyngolaryngoesophagectomy with bilateral neck dissection and gastric pull-up through cervical, right thoracic, and abdominal incisions. We also partially resected the aberrant right subclavian artery with reimplantation in the right common carotid artery. To our knowledge, this is the first report of pharyngolaryngoesophagectomy with transposition of an aberrant right subclavian artery.

Thoracic Epidural Analgesia and Acute Pain Management

AIN continues to be a significant problem for many patients after major surgery. In addition to improving patient satisfaction and decreasing pain scores, enhanced perioperative pain control can improve clinical outcomes. Thoracic epidural analgesia (TEA) remains a critical tool for anesthesiologists to use in acute pain management. TEA is particularly effective for reducing pain after thoracic and upper abdominal surgery and likely permits major surgical procedures to be performed on patients with moderate to severe comorbid diseases, who several years ago may have been determined to be too great a risk for surgery. In the past 10 yr, peripheral nerve blockade has improved perioperative analgesia for patients undergoing extremity surgery. Although nerve blocks have reduced the use of continuous lumbar epidural analgesia, anesthesiologists must understand the indications, placement techniques, solutions administered, potential complications, and evidence-based outcomes for TEA in acute pain management. Indications

Complications of the Chest Wall and the Respiratory System After Surgery and Functional Performance

In a population of patients after successful heart surgery for congenital heart defects (CHD) might emerge noncardiac morbidities. Malfunction of the respiratory system (RS) including chest wall deformities (CWD) may represent risk for a long-term functional performance and QoL of these subjects. This review aims for the long-term (abnormal pulmonary hemodynamics prior to surgery) or short-term (e.g. thoracotomy) harmful impacts on the developing RS. CHD with redundant lung recoil may induce dramatic worsening of the mechanical properties of the RS. Despite successful repair of CHD harmful and successive adaptive processes may affect future development of the RS. Surgical treatment of CHD requires thoracic wall incision (median sternotomy or lateral thoracotomy), which currently with other perioperative impacts may represent unfavourable formation of CWD. Surprisingly, heart surgery itself does not lead either to an improvement or marked change in the severity or frequency of preoperative lung abnormalities (mostly lung volume restriction, hyperinflation, stiff lung or airway obstruction). Causes of RS dysfunction and CWD in patients after surgical repair of CHD are multifactorial. Therefore, a management of these abnormalities especially in adult and aged CHD is difficult. The early primary repair of CHD and recent interventional approaches (e.g., superior ministernotomy or usage of Amplatz occluder) may provide advantages regarding developing organ systems and prevent secondary changes of the heart and the RS. Further research should focus on individual factors in the development of CWD and postoperative respiratory changes. Long-term and/or probably permanent follow up of subjects after CHD repair is a must.

Single incision Nuss procedure for pectus excavatum

To describe a unique single incision modification of the Nuss procedure and compare results to a historical cohort of standard Nuss patients. A retrospective review of 32 patients who underwent the Nuss procedure at a tertiary academic medical center over a 4-year period (2007-2010). Fourteen consecutive patients who underwent the modified technique (MN) were compared to the previous 18 patients who underwent the standard procedure (SN). We evaluated for differences between group demographics, operative variables, and postoperative course. The major technical modification was performing the entire procedure through a single right lateral thoracic incision. The dissection for bar placement on the left side of the chest was performed in a subcutaneous, pre-sternal and pre-muscular plane from the right-sided incision. The bar was placed from the right side and positioned in the standard fashion. Thoracoscopy was preformed via the same incision using a 45-degree thoracoscope and multiple trocar positions. The bar was anchored to the chest wall with a unilateral bar stabilizer. There were no statistically significant differences between the study groups in any of the patient, operative or postoperative care parameters. The single incision modified Nuss procedure is as safe and efficacious as the standard technique.