Thoracoabdominal Approach Research Articles

Primary Rectal Lymphoma Responding to Chemotherapy as Sole Treatment: A Case Report

To define the clinicopathologic profile, management, and outcomes of esophagogastric junction (EGJ) adenocarcinoma in a Philippine tertiary hospital setting. Data were obtained for 88 patients who had curative surgery for EGJ adenocarcinoma from 2004-2013 in Philippine General Hospital. Student's t-tests, analysis of variance, Chi-square and Fisher’s exact tests were used for comparisons and Cohen’s kappa index for correlation. P ≤ .05 was considered significant. Patients were 81.2% male with mean age 55.2 years. 8% were clinical Siewert type I, 23.9% type II, 15.9% type III, and 52.3% unknown. Surgical approach and resection differed across Siewert types (P <.000). Thoracoabdominal approach (72.7%) and total gastrectomy with distal esophagectomy (77.3%) were most commonly performed. Many had at least pathologic T3 (80.6%), N2 (54.5%), and stage III (68.2%) disease. Neoadjuvant and adjuvant chemotherapy were given to 1.2% (1/82) and 48.6% (18/37) of patients. In-hospital morbidity and mortality rates were 40% and 4.5%. 1-year disease-free and overall survival rates were 69.4% and 76.5%. Correlation was fair between preoperative and pathologic Siewert type (P = .003) and poor between clinical and pathologic stage (P = .115). Patients with recurrence had higher pathologic lymph nodes (P = .029) and stage (P = .022). EGJ adenocarcinomas were frequently locally advanced at presentation and associated with poor outcomes. Surgery should be individualized and multimodality approach considered.

Two stage correction of rigid adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) is diagnosed in patients of 11–17 years old. Curvatures of 40 –50 at skeletal maturity have the potential to progress approximately 1 each year. Curvatures of [80 with a thoracic apex are associated with shortness of breath. Therefore, most surgeons offer surgery to patients with curves[45 . Curve flexibility is assessed using bending plain radiographs. An anterior release can be used in order to allow a greater correction of rigid curvatures. We describe a 2-staged procedure; firstly the anterior release via a thoraco-abdominal approach, and secondly a posterior correction of scoliosis using instrumentation. Case description

A Novel Technique of Anti-reflux Esophagogastrostomy Following Left Thoracoabdominal Esophagectomy for Carcinoma of the Esophagogastric Junction.

We developed an anti-reflux technique of intrathoracic esophagogastrostomy, based on the "Kamikawa procedure" or "Double flap technique", which is sometimes used in Japan after open proximal gastrectomy for early upper gastric cancer. We applied this technique to four patients with tumors of the esophagogastric junction. All four patients underwent lower esophagectomy and proximal gastrectomy via a left thoraco-abdominal approach. This procedure includes four steps. Firstly, "double door" seromuscular flaps were created at the anterior wall of the gastric tube. Secondly, the inferior end of the mucosal "window" was opened. Thirdly, suturing was performed between the esophagus and the gastric mucosal "window". Finally, the anastomosis was covered by the seromuscular flaps. No patient experienced post-operative morbidity, or suffered from reflux, even in the Trendelenburg position, dysphagia, or belching. Although this procedure has only been applied to a limited number of patients, we consider that this anastomosis surgical technique is a promising approach to the prevention of reflux after esophagogastrostomy.

Novel posterior technique to temporize life-threatening hemorrhage after great vessel laceration during posterior osteotomy.

Great vessel injury during posterior 3-column osteotomy is rare, but potentially fatal. Literature review revealed limited data guiding spine surgeons during this major catastrophe. In this study our aim was first, to present our case of mortality; second, to discuss a novel technique that can be performed to temporize hemorrhage in a life-threatening situation where an iatrogenic great vessel injury occurs and hemodynamic stability cannot be achieved through usual means of hemostasis; third, a cadaveric study to determine if this novel technique is feasible. Three fresh cadavers including thoracic, lumbar, and pelvis were used. A thoraco-abdominal approach was used to access great vessels at the level of L3. The aorta and vena cava were identified and tagged. The cadavers were turned prone; a pedicle subtraction osteotomy was performed at the level of L3. A novel posterior peri-vertebral approach was used to reach the great vessels. The aorta and vena cava were occluded digitally with this approach and success confirmed visually through the thoraco-abdominal incision. Timing of the procedure and structures at risk were recorded. In all three cadavers, we were able to successfully occlude the great vessels from a prone position. The average amount of time it took to digitally occlude the great vessels was less than a minute. Structures at risk included the L1 and L2 nerve roots, lumbosacral plexus, and the sympathetic trunk. The posterior peri-vertebral approach can potentially be used by a spine surgeon during a life-threatening situation to temporarily occlude great vessel hemorrhage while waiting for the assistance of a vascular/trauma team.

Left-sided foramen Morgagni hernia repair

Clinically evident hernia through the foramen of Morgagni is uncommon at any age. It is rarest of all the diaphragmatic hernias and incidence is 3–4 % of all the diaphragmatic hernias. About 90 % of Morgagni hernia occurs on the right, 8 % bilateral, and only 2 % are limited to the left. A 10-year-old child was referred to us with complaints of shortness of breath on exertion and repeated lower respiratory tract infections since age of 1 year. X-ray chest showed bowel loops in the left side of chest makes a diagnosis of diaphragmatic hernia. Computerized tomogram scan of the chest showed a large defect anteriorly retrosternally on left side herniating the small bowel, large bowel, and spleen in the left chest, and the left lung was hypoplastic. Surgical repair was done through the left thoracoabdominal approach and was repaired using polypropylene mesh. Postoperative recovery was uneventful. We are reporting this case because of a rare and unusual presentation in this patient. Foramen of Morgagni hernias are detected more often in women than in men and more often in obese people than in those of average or below-average weight. Our case was a young, underweight, male child.

Reduced morbidity in resection of residual tumors after chemotherapy for seminoma

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) is associated with complications and decreased adjunctive surgery. Little data are available concerning PC-RPLND in patients with advanced seminomas and residual retroperitoneal tumor lesions. We examined intra- and postoperative complications as well as the frequency of adjunctive surgeries in patients with seminoma and compared the data to a cohort of patients with non-seminomatous germ cell tumors (NSGCT) who underwent PC-RPLND. In our retrospective analysis, 580 patients (43 patients with advanced seminomas and 537 patients with NSGCT) underwent PC-RPLND between 1989 and 2010. The surgical approach was preferred via midline incision or a thoracoabdominal approach depending on the location of the residual tumor. Of the 43 patients with seminoma, a total number of 13 adjunctive surgeries were performed in 7 patients. There were only three intraoperative complications, two postoperative complications (prolonged intestinal paralyses). There were no significant differences in adjunctive surgeries and postoperative complications (p=0.49 and p=0.133) between the two groups. There were significantly fewer intraoperative complications in favor of seminomas (p=0.001). PCRLND in seminomas and NSGCT is a demanding surgical intervention. In contrast to other series we did not find significant differences in the two patient groups concerning adjunctive surgeries and postoperative complications. The indication for PCLND in patients with seminoma is limited, but if necessary it can be performed safely in experienced centers.

Surgical management of congenital scoliosis

Objective The aim of this study was to assess outcomes and complications in patients surgically treated for congenital scoliosis. Background Congenital scoliosis due to hemivertebra and unsegmented bar is most often progressive and requires surgical treatment. The recommended surgical options include 'in-situ' fusion, convex hemiepiphysiodesis, and hemivertebra excision. Patients and methods This study included 20 patients (six boys and 14 girls). The age at operation was between 4 and 18 years. Two techniques were used: the anterior procedure and the posterior procedure. The anterior procedure involves thoracotomy and the thoracoabdominal approach. In this procedure disc excision above and below the level of the anomaly was performed and the segment of the vertebral column (hemivertebra, segment of unsegmented bar) that would be excised was determined. In the posterior procedure, posterior correction, fixation, decortications, and grafting were performed. Fixation was carried out using claw, sublaminar wires, pedicular screws, and rods. Results 'In-situ' fusion does not address the anomaly directly; it allows a moderate correction rate but is associated with long spinal fusion. Hemivertebral resection directly addresses the spinal anomaly; it produces the best correction results and is a safe procedure to perform. The average angle after posterior correction and fusion of congenital scoliosis was 37.5΀ (range from 15 to 60΀). The percentage of correction was 55% (range from 20 to 90%). The early postoperative correction following the staged combined anterior and posterior correction, and fusion was 60%, ranging from 40 to 80΀. Conclusion The treatment of congenital scoliosis focuses on early diagnosis and appropriate surgical management before the development of large curves. All of the procedures described can be effective and safely performed if correctly selected and performed by an experienced team of surgeons.

Patterns of Chest Injuries among Yemeni Patients: a Retrospective Analysis

Objective: To investigate the patterns of thoracic injuries and the methods used for their management. Methods: A retrospective descriptive analysis of 275 chest trauma cases managed at the University of Science and Technology Hospital over the period 2010–2013. Results: Of 275 consecutive patients with chest trauma, 72.7% were males and 7.27% were females with a mean age of 33.6 years old. Blunt injuries represented 51% (125 males and 15 females) while penetrating injuries represented 49% (130 males and five females) of the cases. Among the penetrating injury group, three patients (1.1%) were with direct sustaining cardiac injuries. The most common presenting features associated with injuries were pain (100%), dyspnea (78.6%) and hemorrhagic shock (17%). Concurrent extrathoracic injuries were found in 22.2% (61/275) of the total chest injuries; spinal cord injuries (3.3%; 9/275), brain injuries (6.2%; 17/275) and intraperitoneal injuries (4.4%; 12/275) and bone fractures (7.3%; 23/275). The first three types of extrathoracic injuries were mostly due to penetrating injuries that necessitated a thoracoabdominal approach or chest tube drainage (CTD) and laparotomy. Computerized tomography scan, chest X-ray, ultrasound and echocardiography were the main diagnostic tools, being used for the diagnosis of 95.27%, 96.72%, 9.73% and 9.33% of cases, respectively. Intercostal tube thoracostomy was required for the management of 96.3% (130/135) of patients with penetrating injuries; early thoracotomy was performed in 25.9% (35/135) of patients to control over bleeding while late thoracotomy was performed in 16.3% (22/135) of patients for removal of retained foreign body and empyema. The CTD was performed in 76.4% (107/140) of patients with blunt injuries, whereas 23.6% (33/140) patients had conservative management and only 2.9% (4/140) of patients underwent thoracotomy. The average hospital length of stay was 6 days for penetrating trauma group and about 7 days for blunt trauma group. Out of all admitted cases, 94.5% (260/275) were cured while 5.5% (15/275) died. Conclusions: It is concluded that CTD is the most appropriate method of treating complicated chest injuries; however, the penetrating trauma has a higher rate of internal damage that requires early intervention to save life, especially for severe or progressive intrathoracic bleeding and cardiac injury. Pulmonary contusion and rib fracture were the most common complications of chest traumas, for which strong painkillers, anti-infective therapy, respiratory care measures and mechanical ventilation are the components of an effective treatment strategy. The associated extrathoracic injuries constitute a major prognostic factor in chest traumas, which were higher in blunt traumas.

Cancro do Esófago: Estratégia de Abordagem Cirúrgica

Oesophagectomy for cancer is associated to a significant morbidity and mortality. The superiority of transthoracic vs transhiatal is still a matter of controversy. The aim of this paper is to discuss the results of a series of patients submitted to either a transthoracic or a transhiatal according to the anatomic location regarding the carina. Retrospective analysis of 52 consecutive patients, with oesophageal carcinoma, 7 female and 45 males, median age 64 [46-85] years. Location: cervical - 1; above carina - 22; below or at carina level - 19; cardia type I -10. 19 adenocarcinoma, 32 squamous cells, 1 lymphoma. Twenty patients (40%) - neo-adjuvant therapy. Thoracoabdominal approach - 3, cervico-thoracoabdominal - 20, transhiatal - 27, exploratory thoracotomy - 2. Gastric pull-up 49 (cervical anastomosis - 46; thoracic - 3); cervical oesofagocoloplasty -1. Pathologic staging: complete remission - 8; Ib - 3; IIa - 9; IIb - 4; IIa - 11; IIIb -2; IIIc - 10; IV - 1; non-stageable - 3. Major complications: 37%. Resectability: 96% (50/52). Mortality: 4th week - 6%; in-hospital - 14%. Median survival 18 months [3-80]. Survival Curves (Kaplan-Meier): 2 years - 47%; 5 years - 19% (transthoracic vs transhiatal p > 0.05). Selection of surgical approach based on the anatomic location of the tumour regarding the carina was safe, the resectability was high and similar when a transthoracic or a transhiatal was planed and carry-on. In this series of oesophageal cancer patients, in advanced pathologic condition (52% p Stages III/IV) the overall survival was similar for transthoracic and transhiatal. Neo-adjuvant treatments definitively contributed to enhance resectability.

Safe hepatectomy selection criteria for hepatocellular carcinoma patients: a validation of 336 consecutive hepatectomies. The BILCHE score.

Selection criteria for hepatectomy for hepatocellular carcinoma (HCC) are object of debate. We presented our criteria for safe hepatectomy for HCC, and we compared the results with those obtainable using the most common scores for HCC. All patients submitted to hepatectomy for HCC based on the same criteria were reviewed from our prospectively maintained database. Such criteria included bilirubin (BIL), cholinesterases (CHE), ascites, esophageal varices, and residual liver volume. A total of 336 patients were analyzed. One hundred fifteen patients (33 %) had thoracoabdominal approach, but only 39 (12 %) had major or extended resections. The median tumor number was 1 (range 1-33), while the median tumor size was 3.6 cm (range 1.1-28). Of those, 94 (29 %) had postoperative complications, of which 6 % were graded as major (Dindo III-IV). The 90-days mortality was 2 %. The MELD, APRI, and CPT scores were not found to be statistically significant for complications, while combining BIL and CHE we defined four classes of risk. The association of BIL >1 mg/dl (>17.1 µmol/l) and CHE ≤ 5,900 U/l was the best to detect complications (OR = 4.45; P = 0.007). This study shows that our selection criteria that count mainly on two commonly available, and inexpensive parameters, BIL and CHE, lead to identify patients potentially at risk of postoperative complications after hepatic resection for HCC. NCT02056041 ( http://www.clinicaltrials.gov).

P-0017 - Local Recurrence Rate Following Total Gastrectomy by Transabdominal Approach for Siewert'S Type II Esophagogastric Junction Adenocarcinoma

Introduction: The optimal approach for radical surgery in patients with Siewert's type II esophagogastric junction (EGJ) cancer remains uncertain. Some authors consider esophagogastrectomy by thoracoabdominal approach or esophagectomy with hemigastrectomy for Siewert's type II EGJ cancer to be standard in terms of more radicalism, while the others prefer extended total gastrectomy by abdominal approach and accept it being more adequate for avoiding higher complication and death rate. The aim of this trial is to study the local recurrence rate at region of esophagojejunal anastomosis in order to clarify the adequacy of extended total gastrectomy by transabdominal approach for Siewert's type II EGJ cancer.

Surgical anatomy of the diaphragm in the anterolateral approach to the spine: a cadaveric study.

Laboratory cadaveric study. To delineate the pertinent surgical anatomy of the diaphragm during access to the anterolateral thoracolumbar junction. The general anatomy of the thoracic diaphragm is well described. The specific surgical anatomy as it pertains to the lateral and thoracoabdominal approaches to the thoracolumbar junction is not well described. Dissections were performed on adult fresh cadaveric specimens. Special attention was paid to the diaphragmatic attachments to the lower rib cage and to the spinal thoracolumbar junction. The pertinent diaphragmatic attachments to the rib cage are at the 11th and 12th ribs. Whether the diaphragm is incised or mobilized ventrally, the pertinent spinal attachments are the lateral and medial arcuate ligaments. Identifying and sectioning these structures allows for direct access to the thoracolumbar junction, particularly the L1 vertebral body. An understanding of the diaphragmatic-costal and diaphragmatic-spinal attachments is key for the safe and effective implementation of diaphragm mobilization during the lateral and thoracoabdominal approaches to the spine.

Neither a Lumbar Disc nor a Thoracic Disc; L1-L2 Disc Located in Region of Spine Biomechanical and Neural Transition Zone

Introduction Although L1-L2 disc is anatomically located in lumbar region, its specific location poses a caveat to the surgeon for both conus medullaris present in this area and the great biomechanical standpoint in thoracolumbar region. Materials and Methods In our experience with this group of patients, we used trans-facet pedicle-sparing approach to care for conus medullaris. In addition, we performed short segment fusion to augment this highly demanding biomechanical region. Since the year 2008, we operated 13 cases with L1-L2 disc with this technique. Only two cases presented with severe L2 radiculopathy and the rest came with feature of cauda equine or conus problem. Axial back pain was crucial symptom in eight cases. Two patients had simultaneous disc problem in L2-L3 and one patient had T12-L1 disc protrusion. After operation, patients received Jewett hyperextension brace for 3 months. In one patient with central hard calcified disc, we performed thoracoabdominal approach and decompression from anterior. All surgery performed under high magnification of microscope and bone removal was done by powered drill. Results In six cases, decompression was performed bilaterally to reach the central portion of the disc. Pedicle screw was used for fixation in all patients. TLIF banana cage was used in five cases and spinous process bone used as interbody graft in four cases. There was no aggravation in neurological deficit and we have no problem with CSF leak or wound. Fusion achieved in all patients and axial back pain resolved successfully. Conclusion Although L1-L2 innately considered a lumbar disc, we suggest that they should be considered as thoracic disc and the surgeon should not solely rely on where the conus terminated in MRI. In this location, small traction can lead to catastrophic neurological damage; therefore, by using trans-facet pedicle-sparing under microscopic guide the cord should be decompressed by drill. In addition, to prevent neurological injury, Kerrison should not be placed under already stenotic canal. Disclosure of Interest None declared

Thoracoabdominal approach in liver surgery: how, when, and why

Liver resection can be performed with different surgical approaches whether abdominal or combined thoracoabdominal. This work focuses on the surgical technique for the thoracoabdominal approach in liver surgery, describing the technique, the rationale, and making a review of the current literature on such subject.

Impact of Surgery on Quality of Life in Patients with Hepatocellular Carcinoma

Liver resection is the mainstay of curative treatment for localized hepatocellular carcinoma (HCC). However, the impact of surgery for HCC on quality of life (QOL) has not been well assessed. Health-related QOL was assessed using the Short Form-36 questionnaire in 108 patients who underwent a liver resection for HCC between January 2004 and January 2008. The QOL assessment was scheduled before and every 3 months after the operation. Patients were divided into two groups based on patient-, tumor-, and surgery-related variables. The physical component summary (PCS) and mental component summary (MCS) were compared between the two groups. Altogether, 69 patients (64 %) completed the consecutive QOL assessments until 6 months after surgery. At 3 months, the PCS scores were significantly lower for women and for patients who had undergone thoracotomy than among men (p = 0.010) and patients who had not undergone thoracotomy (p = 0.048), respectively. No significant differences in any of the PCS scores were observed at 6 months. No significant differences in the MCS scores were observed between the groups throughout the investigation, and improvement relative to the preoperative status was observed at 6 months. Physical impairments in the QOL after surgery had returned to the baseline at 6 months, and the postoperative mental QOL improved relative to the preoperative state. The surgical candidates were expected to have a satisfactory QOL regardless of the preoperative status and surgical outcomes. A thoracoabdominal approach had a transient negative impact on the physical health status.

Microcirculatory perfusion shift in the gut wall layers induced by extracorporeal circulation

Extracorporeal circulation (ECC) is regularly applied to maintain organ perfusion during major aortic and cardiovascular surgery. During thoracoabdominal aortic repair, ECC-driven selective visceral arterial perfusion (SVP) results in changed microcirculatory perfusion (shift from the muscularis toward the mucosal small intestinal layer) in conjunction with macrohemodynamic hypoperfusion. The underlying mechanism, however, is unclear. Therefore, the aim of this study was to assess in a porcine model whether ECC itself or the hypoperfusion induced by SVP is responsible for the mucosal/muscular shift in the small intestinal wall. A thoracoabdominal aortic approach was performed in 15 healthy pigs divided equally into three groups: group I, control; group II, thoracic aortic cross-clamping with distal aortic perfusion; and group III, thoracic aortic cross-clamping with distal aortic perfusion and SVP. Macrocirculatory and microcirculatory blood flow was assessed by transit time ultrasound volume flow measurement and fluorescent microspheres. In addition, markers for metabolism and intestinal ischemia-reperfusion injury were determined. ECC with a roller pump induced a significant switch from the muscularis and mucosal layer of the small intestine, even with adequate macrocirculation (mucosal/muscular perfusion ratio: group I vs II, P = .005; group I vs III, P = .0018). Furthermore, the oxygen extraction ratio increased significantly in groups II (>30%) and III (>40%) in the beginning of the ECC compared with the control (group I vs II, P = .0037; group I vs III, P = .0062). Lactate concentrations and pH values did not differ between groups I and II; but group III demonstrated a significant shifting toward a lactate-associated acidosis (lactate: group I vs III, P = .0031; pH: group I vs III, P = .0001). We demonstrated a significant shifting between the small intestinal gut wall layers induced by roller pump-driven ECC. The shift occurs independently of macrohemodynamics, with a significant effect on aerobic metabolism in the gut wall. Consequently, an optimal intestinal perfusion cannot be guaranteed by a roller pump; therefore, perfusion techniques need to be optimized.

Retroperitoneal lymph node dissection in post-chemotherapy residual mass with 360-degree involvement of the aorta

Post-chemotherapy retroperitoneal lymph node dissection in cases with encasement of major vessels is a formidable surgery. A 25-year-old man presented to us after a right high inguinal orchidectomy that showed a mixed germ cell tumor with predominant embryonal cell carcinoma elements. Following four cycles of bleomycin, etoposide and cisplatin (BEP), the serum markers had normalized but a large retroperitoneal mass predominantly on the left side encasing the large vessels including the left renal hilum persisted. A thoraco-abdominal approach was taken and the supraceliac aorta was defined, and the large mass encasing the left renal hilum was excised along with a left nephrectomy. The preaortic mass was divided applying the “split and roll” technique and subsequently removed. The interaortocaval and the precaval regions were also subsequently cleared. The aorta and the IVC were preserved and cleared completely of the tumor mass. Post-chemotherapy large residual lymph nodes present a difficult challenge in managing testicular malignancies especially if they encase major vessels that need to be preserved. Careful approach to tumor resection and standard surgical principles for lymph node dissection need to be followed to ensure a successful outcome.

Primary Hepatic Leiomyosarcoma: A Rare Diagnosis with an Anticipated Outcome

Purpose: Primary hepatic sarcomas (PHS) represent <1% of all hepatic malignancies, and are classified according to their histologic features. Primary hepatic leiomyosarcoma (PHL) is one variant, which has poorly characterized prognostic factors and lacks an optimal management protocol due to its rarity. We present a case of PHS in a 34-year-old African-American male. He had a 7-month history of intermittent back pain before presenting with right upper quadrant abdominal pain, worsening dyspnea, and bilateral lower extremity swelling. On exam, he was found to have fever, abdominal distension with a palpable mass in the epigastric area, and +3 lower extremity edema. He had anemia (9.9 g/dL) and abnormal liver function tests. Radiologic imaging revealed a 17-cm complex mass in the right lobe of the liver. A liver biopsy was performed. Immunohistochemistry revealed tumor cells reactive for smooth muscle actin and desmin, which was consistent with high-grade leiomyosarcoma. He underwent right hepatic lobectomy via a thoracoabdominal approach. A 32 x 23 x 13.5 cm hemihepatectomy specimen was resected with portions of adherent diaphragm, leaving the diaphragmatic margin free of involvement. The patient subsequently received chemotherapy with Ifosfamide and mesna for residual tumor, which was well tolerated. The patient is doing relatively well 24 months after tumor resection, with no recurrence to date. This rare case of PHL is one of 30 cases reported in the English literature. Prognosis is influenced by the ability to resect the tumor completely. Liver transplantation (OLT) in such patients was accompanied by early high recurrence with poor outcomes after 1 year. In our patient, a good outcome was obtained with resection and chemotherapy, despite having advanced disease. International multi-registry efforts need to be established to assess the most effective therapeutic modalities for PHL.Figure: Primary hepatic leiomyosarcoma: 32 x 23 x 13.5 cm specimen.

294 * OPEN AORTIC REPAIR FOR THORACOABDOMINAL AORTIC ANEURYSM: A SINGLE-CENTRE FIVE-YEAR EXPERIENCE WITH 250 CASES

Objectives: Recently, the technology of endovascular devices has advanced. These advances have led to alternative approaches to thoracoabdominal aortic aneurysm (TAAA) repair. However, in some cases, endovascular aortic repairs are still limited in their indications because of the morphology of the aneurysms. These innovative approaches must be compared with conventional open aortic repair. To facilitate such comparisons, we have evaluated contemporary outcomes of open TAAA repair. Methods: We retrospectively reviewed and analysed data collected from January 2008 to December 2012 on 252 consecutive patients who underwent TAAA repair with a left thoracoabdominal approach in our institution. Results: A total of 134 patients (53.2%) had atherosclerotic aneurysm without dissection, and 114 patients (45.2%) had chronic dissection. The mean maximum aneurysm diameter was 61 mm. There were 15 patients with Marfan syndrome. There were 39 (11.5%) urgent or emergency repairs. One-hundred and fifteen patients (45.6%) underwent extensive repairs (Crawford extents I and II). Two-hundred and five patients (81.3%) had cerebrospinal fluid drainage. We used left heart bypass in 231 patients (91.6%). The overall operative mortality was 7.5% (19 of 252). Mortality tended to be higher after urgent or emergency repairs (24.1%, 7 of 29) than after elective repairs (5.4%, 12 of 223). Permanent paraplegia occurred in 15 patients (6.0%). Conclusions: Open aortic repair of TAAA was characterized by acceptable early outcomes, particularly when repair is elective, in our institution. Our method can be selected regardless of the form of aneurysm in most cases. Such results should be compared with those of evolving approaches including endovascular and hybrid repairs.

Spinal reconstruction for osteomyelitis with free vascularized fibular grafts using intra‐abdominal recipient vessels: A series of three cases

Reconstruction of bony defects in the surgical management of vertebral osteomyelitis is a challenging endeavor. Our objective is to report the use of intra-abdominal vessels as the recipient vessels for microanastomosis of vascularized bone graft and the use of a spinal cage for fixation. Three patients failed conservative treatment for vertebral osteomyelitis and suffered pathologic fracture. Their treatment consisted of staged posterior irrigation and debridement with segmental fixation, followed by a thoracoabdominal approach multiple-level corpectomy. Reconstruction was performed with a free vascularized fibular graft placed within a custom, expandable cage. The vascularized fibular graft was anastomosed to an intra-abdominal recipient vessel. All patients improved clinically with no neurologic deficits noted. All showed evidence of successful fusion. Free vascularized bone grafts continue to be an excellent option for multi-level spinal defects related to osteomyelitis. Intra-abdominal recipient vessels are appropriate recipient vessels, as their diameter, length, and accessibility allow vascularized bone graft reconstruction of vertebral column defects of the thoracolumbar region. These vessels are also easily accessible and the anastomoses can be performed in the superficial operating incision.