Transpleural Approach Research Articles

Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR).

Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality (AR). Materials and Methods: All patients who underwent surgery for calcified thoracic herniated disc via a transthoracic transpleural approach at our Department using iCT and microscope-based AR were included in the study. Results: Six consecutive patients (five female, median age 53.2 ± 6.4 years) with calcified herniated thoracic discs (two patients Th 10-11 level, two patients Th 7-8, one patient Th 9-10, one patient Th 11-12) were included in this case series. Indication for surgery included evidence of a calcified thoracic disc on magnet resonance imaging (MRI) and CT with spinal canal stenosis of >50% of diameter, intractable pain, and neurological deficits, as well as MRI-signs of myelopathy. Five patients had paraparesis and ataxia, and one patient had no deficit. All surgeries were performed in the lateral position via a transthoracic transpleural approach (Five from left side). CT for automatic registration was performed following the placement of the reference array, with a high registration accuracy. Microscope-based AR was used, with segmented structures of interest such as vertebral bodies, disc space, herniated disc, and dural sac. Mean operative time was 277.5 ± 156 min. The use of AR improved orientation in the operative field for identification, and tailored the resection of the herniated disc and the identification of the course of dural sac. A control-iCT scan confirmed the complete resection in five patients and incomplete resection of the herniated disc in one patient. In one patient, complications occurred, such as postoperative hematoma, and wound healing deficit occurred. Mean follow-up was 22.9 ± 16.5 months. Five patients improved following surgery, and one patient who had no deficits remained unchanged. Conclusions: Optimal surgical therapy in patients with calcified thoracic disc disease with compression of dural sac and myelopathy was resectioned via a transthoracic transpleural approach. The use of iCT-based registration and microscope-based AR significantly improved orientation in the operative field and facilitated safe resection of these lesions.

Surgical bypass to the left subclavian artery: an extra-anatomical transpleural approach

A distal anastomosis in zone 3 is technically demanding during the frozen elephant trunk procedure. Proximalization of the distal anastomosis to zone 2 with subsequent revascularization of the left subclavian artery is an attractive alternative. This video tutorial describes the technique of an extra-anatomical bypass from the aortic prosthesis to the infraclavicular left subclavian (axillary) artery in arch replacement with the distal aortic graft anastomosis in zone 2.

Combined retropleural thoracotomy and posterior spinal approach for thoracic dumbbell Schwannoma: Case series and review of the literature

BackgroundDumbbell schwannomas of the thoracic spine are challenging to cure surgically. Surgeons are familiar with posterolateral approaches to the spine, however, these may provide inadequate exposure for large tumors extending to ventral extraspinal compartments. Ventrolateral transpleural approaches offer direct access to the ventral thoracic spine and intrathoracic cavity, though are associated with increased morbidity and pulmonary complications, and may necessitate a staged procedure in order to address concomitant dorsal pathology. Herein we describe our experience with single-stage, posterior approach to dumbbell schwannomas with large ventral extraspinal components, and review the literature regarding surgical approaches for these tumors. MethodsRetrospective review of patients who underwent a single-stage, posterior spinal surgery for thoracic dumbbell schwannomas from 2008 to 2018. Inclusion criteria were age > 18 years and ventral thoracic tumor component. ResultsThree patients underwent a simultaneous retropleural thoracotomy and posterior spinal approach, through a single incision, for the resection of dumbbell (intradural and extradural) schwannomas. Mean age was 49.7 years and 2 patients were female. All patients were neurologically intact at baseline. Lesions were 4–8.2 cm in the largest dimension (mean 6.1 cm). GTR was achieved in all patients. One pleural rent occurred intraoperatively; there were no other intraoperative or perioperative complications. At a mean follow-up of 14.1 months all patients remained motor and sensory intact and there was no evidence of recurrence. ConclusionsThe combined retropleural thoracotomy-posterior spinal approach provides safe and sufficient access for resection of large dumbbell schwannomas of the thoracic spine.

A case report of a lung abscess as a rare complication of a pyogenic liver abscess

Rationale:A hepatobronchial fistula and lung abscess following a pyogenic liver abscess is a rare entity and it is not easy to diagnose this condition based on the symptoms and chest radiography.Patient concerns:An 81-year-old man presented with productive cough and dyspnea.Diagnosis:Chest radiography indicated increased opacities in the right lower lung field with an air-fluid level suggestive of pneumonia complicated by a lung abscess. Chest and abdominal computed tomography revealed an abscess in the right lower lung field that bordered an abscess at segment 7 of the liver. Tubography confirmed a fistula between the liver and lung abscesses.Interventions:Due to communication between 2 abscesses, transhepatic approach was done instead of transpleural approach to avoid complications.Outcomes:A liver abscess complicated by a lung abscess was resolved following percutaneous transhepatic drainage of the liver abscess and antibiotic administration.Lessons:Though uncommon, the lack of suspicion of sub-diaphragmatic liver abscess often lead to a delay in diagnosis and proper treatment. Our case implies the importance of computed tomography in early diagnosis of liver abscess in case of lung abscess in the right lower lung field.

Safety and Efficacy of Percutaneous Image-Guided Mediastinal Mass Core-Needle Biopsy.

ObjectiveTo retrospectively evaluate the safety and efficacy of percutaneous image-guided mediastinal mass core-needle biopsy.Patients and MethodsRetrospective review of an institutionally maintained biopsy registry identified 337 computed tomography– or ultrasound-guided percutaneous mediastinal mass core needle biopsies between October 2002 and August 2017 in a single quaternary referral center. Mean patient age was 51 (range, 18 to 93) years. Procedural techniques, anticoagulation/antiplatelet therapy, and tumor anatomical characteristics were reviewed. Classification and gradation of complications was based on the Clavien-Dindo system. Diagnostic yield was defined as the ratio of diagnostic biopsy to all biopsies performed.ResultsMean tumor size was 59.2 (range, 10 to 180) mm with 89.9% (n=303) of lesions located in the prevascular (anterior) mediastinum. There was a single major complication (0.3%) of a symptomatic pneumothorax requiring intervention. There were seven (2.1%) minor complications, including three bleeding complications. A transpleural approach was the only variable associated with an increased complication rate (P<.01). Forty-one (12.2%) patients had a biopsy performed while taking an antiplatelet/anticoagulant agent within the therapeutic window, with a single case (0.3%) associated with a minor bleeding complication. Of 18 (5.3%) procedures performed without cessation of anticoagulant/antiplatelet therapy, there were no bleeding complications. Of all 337 biopsies, 322 (95.5%) were diagnostic. None of the analyzed variables were significantly associated with a nondiagnostic biopsy.ConclusionImage-guided percutaneous core-needle biopsy of mediastinal masses is a safe procedure with high diagnostic yield. Further prospective studies are required to assess the complication profile in higher risk patients.

Video-Assisted Thoracic Surgery Thymectomy: Transpleural Approach.

There are several types of minimally invasive approaches for thymectomy, of which the transpleural approach by video-assisted thoracoscopic surgery is particularly useful. In this approach, thymectomy is performed from either side of the thoracic cage. Thoracic surgeons should be familiar with the principles of the procedure, the anatomy of the region, and surgical strategies for successful thymectomy. The details of transpleural thymectomy are discussed herein.

Сhylothorax

Objective — to determine and analyze, on our own experience, effective methods of treating chylothorax.&#x0D; Materials and methods. For the last 15 years on the basis of the department of surgical treatment of tuberculosis and invasive diagnostic methods of the SI «National Institute of Phthisiology and Pulmono­logy named after F.G. Yanovsky NAMS of Ukraine» was treated 21 patients with a diagnosis of chylothorax. Among the concomitant pathologies, the following diseases were most often diagnosed: ischemic heart disease 5 (23.8 %) cases, gynecological diseases 7 (32.9 %), obesity 4 (18.8 %).&#x0D; Results and discussion. An analysis was perfomed, which allows us to conclude that most often (10 cases, 47.6 %) chylothorax was diagnosed in women as a manifestation of lymphangioleiomyomatosis (LAM). It should be noted that in 4 (36.3 %) patients, LAM was diagnosed only by lung biopsy. In 2 (18.1 %) women, chylothorax was bilateral. In 6 (54.5 %) cases, a history of spontaneous pneumothorax (a characteristic diagnostic sign of LAM). The second place among the causes of chylothorax was by intrathoracic lymph node dissection during surgery for lung cancer. In all 3 (14.2 %) cases, the patients underwent left­sided pulmonectomy. Chylothorax usually developed by about 5—7 days, which coincided with the mobilization of patients and the restoration of adequate nutrition. In 2 (9.5 %) patients, the cause of chylothorax was damage to the thoracic duct during neurosurgical intervention through the transpleural approach. Such chylothorax is characterized by an aggressive course, quickly leads to exhaustion of the patient and requires immediate surgical intervention to ligate the thoracic duct below the level of injury. In 2 (9.5 %) patients, chylothorax was one of the manifestations of idiopathic pulmonary ossification. It should be noted that the diagnosis of pulmonary ossification was established only after a histological examination of a biopsy specimen, while such patients were admitted to the clinic with a diagnosis of recurrent pleurisy. In both cases, it was possible to achieve cessation of lymphorrhea by using parietal pleurectomy and conservative therapy. A feature of these patients is the fact that even with the elimination of chylothorax, moderate manifestations of respiratory failure remained in them. Chylothorax in lymphoproliferative diseases — in 2 cases (9.5 %) was the result of the prevalence of the oncological process, and therefore after its diagnosis, only pleural punctures and symptomatic treatment were performed. In no case was it possible to achieve complete cessation of lymphorrhea. In 1 (4.7 %) patient, idiopathic right­sided recurrent chylothorax was observed with moderate hilar lymphadenopathy. Videothoracoscopic biopsy of the intrathoracic lymph nodes was supplemented with parietal pleurectomy. This made it possible to achieve a reliable cessation of lymphorrhea, however, according to the data of a histopathological study, only reactive nonspecific changes were presented in the lymph nodes. In another 1 (4.7 %) case, on the 4th day after right­sided parietal pleurectomy for chronic pleural tuberculosis, lymphorrhea developed on the side of the operation. Short­term conservative therapy made it possible to achieve a positive result.Thus, the overall effectiveness of the treatment of such a pathological condition as chylothorax was 85.7 %. &#x0D; Conclusions. Chylothorax is a complex medical problem, the effective solution of which depends on a complex of conservative and surgical methods of treatment.The most common cause of chylothorax is lymphangioleiomyomatosis (47.6 %). The overall effectiveness of chylothorax treatment in the clinic is 85.7 %.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases

Purpose The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches. Methods Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12–79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions. Results Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X2 4.13 P:0.042). Severe post-operative neuralgia (VAS 7–10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X2 7.07 p 0.0078). Conclusions MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

Transpleural versus extrapleural approach in treatment of esophageal atresia

BackgroundSurgery is the only curative treatment of patients with esophageal atresia and tracheoesophageal fistula. A lot of surgeons recommend transpleural repair while others prefer extrapleural approach for repair. This study will evaluate the differences, advantages, outcome, and the disadvantages of the two techniques.ResultsDuration of surgery was significantly shorter in the group operated by transpleural approach. The incidence of pneumothorax was higher in patients operated by transpleural approach.ConclusionOperating esophageal atresia and tracheoesophageal fistula by transpleural approach has significantly shorter time of surgery, but there is no difference between the two groups as regards incidence of leakage or mortality.

Repair of Esophageal Atresia With Trache Esophageal Fistula Through Modified Transpleural Approach by Delivering Lung Out of Main Wound

Objectives: To assess the morbidity, mortality, operation time, and postoperative complications in the present modified transpleural (MTP) approach with the conventional extrapleural (EP) approach in esophageal atresia (EA) with tracheoesophageal fistula (TEF).Design: Longitudinal randomized case control study.Setting: Pediatrics Surgery Department of a tertiary care hospital.Study period: November 2009 to December 2011.Participants: Neonates above 1.5 kg body weight with EA and TEF.Results: Sex ratio is 7:3 (male and female). In total, 40% had associate anomalies. Duration of operation in MTP approach from 90 to 110 min (mean duration 98.6 min) where as in EP approach from 120 to 130 min (mean duration 121.4 min). All 3(15% wound infections were in EP group. A total of 3 develops right sided pneumothorax with 2 in MTP and 1 in EP approach group. In total, 10% (2) in MTP approach group and 5% (1) in EP group expired. Leakage in anastomotic site was seen in 2(10%) each in both the groups. Six developed stricture, out of which 4 in EP group, 2 in MTP group.Conclusion: MTP approach is less time consuming, possess less hindrance during operation. Postoperative complications are comparable. Mortality is higher in MTP group than EP group, may be because of associated lethal co morbidity.

CT-Guided Microwave Ablation of Liver Tumors in Anatomically Challenging Locations.

To assess the feasibility and outcome of microwave ablation (MWA) of hepatic tumors in anatomically challenging locations. A total of 94 patients with 174 hepatic tumors referred for CT-guided MWA were included in this retrospective institutional review board-approved study. One hundred and twenty-five tumors (median size 17mm, range 12-24mm) with subcapsular location (n = 91) and/or in which a transpleural approach was applied (n = 53) were identified (group 1) and compared to tumors with a central intrahepatic location (group 2; n = 49, median size 19mm, range 12-23mm). Technical success, complications and local tumor progression (LTP) were evaluated. Risk factors were analyzed using univariate analysis, logistic regression and Kaplan-Meier curves (p < 0.05 deemed significant). Technical success was 100% in both groups. In group 1, complications occurred in n = 31 tumors (24.8%; pneumothorax n = 20; hematoma n = 11). Complications occurred significantly less often in group 2 (8.2%; n = 4 (hematoma); p = 0.011). There were no major complications. Transpleural approach and number of capsule punctures were identified as risk factors for complications (all p < 0.05). Median follow-up was 265days. LTP was comparable between both groups (13.6 vs. 10.2%; p = 0.41). Use of hydrodissection was the only independent factor associated with LTP (p = 0.03, HR 3.29). CT-guided hepatic MWA of subcapsular tumors and subdiaphragmatic tumors requiring a direct or transpleural approach is feasible with increased minor but not major complications. LTP did not differ significantly between both groups.

A rare postoperative complication of anterior lower thoracic instrumentation: diaphragmatic laceration with hemothorax

To highlight the importance of preventing visceral injury due to prominent anterior implants at the spinal column. A 52-year-old man with cord compression was treated with a T9/10 discectomy and instrumented fusion via a right thoracotomy and trans-pleural approach. Postoperatively, he had improved lower limb numbness. However, after a bout of coughing, there was sudden increase in chest drain output, hemodynamic instability and massive fluid collection in the right chest cavity. Emergency re-exploration of the thoracotomy was performed and a 6cm laceration of the right postero-medial diaphragm was identified as the bleeding source and was found to be in close proximity with the locking nut of the anterior implants. The laceration was repaired and a soft synthetic patch was used to cover the implants. Postoperatively, the hemothorax resolved and the patient recovered from the neurological deficit. Prevention of diaphragmatic injury can be performed using lower profile and less sharp-edged implants. Implant coverage with a soft synthetic material is necessary if unable to perform direct repair of the parietal pleura over the implants.

Cierre quirúrgico del ductus arterioso persistente del prematuro: ¿influye la técnica quirúrgica en los resultados?

IntroductionSurgical closure of patent ductus arteriosus in premature neonates is an aggressive technique and is not free of complications. A study was designed with the aim of describing our experience with a less invasive technique, the extra-pleural approach via a posterior minithoracotomy, and to compare the results with the classic transpleural approach. Patients and methodsA retrospective cohort study was conducted on premature neonates on whom surgical closure of the ductus was performed during a ten-year period (March 2005 to March 2015). A comparison was made of the acute complications, the outcomes on discharge, and follow-up, between the extra-pleural approach and the classic transpleural approach. The study included 48 patients, 30 in the classical approach and 18 in the extra-pleural group. ResultsThe demographic and pre-operative characteristics were similar in both groups. No differences were found between the 2 groups in the incidence of acute post-operative complications (56.6 vs. 44.4%), on the dependence on oxygen at 36 weeks (33.3 vs. 55.5%), or in hospital mortality (10 vs. 16.6%). As regards the short-term progress, the extra-pleural group required fewer days until the withdrawal of supplementary oxygen (36.3 vs. 28.9) and until hospital discharge (67.5 vs. 53.2), although only the time until extubation achieved a statistically significant difference (11.5 vs. 2.7, P=.03). ConclusionsThe extra-plural approach by posterior minithoracotomy for the surgical closure of ductus in the premature infant is viable and could bring some clinical benefits in the short-term.

Minimally invasive electro-magnetic navigational bronchoscopy-integrated near-infrared-guided sentinel lymph node mapping in the porcine lung.

BackgroundThe use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) for sentinel lymph node (SN) mapping has been investigated in lung cancer; however, this has not been fully adapted for minimally invasive surgery (MIS). The aim of our study was to develop a minimally invasive SN mapping integrating pre-operative electro-magnetic navigational bronchoscopy (ENB)-guided transbronchial ICG injection and intraoperative NIR thoracoscopic imaging.MethodsA NIR thoracoscope was used to visualize ICG fluorescence. ICG solutions in a 96-well plate and ex vivo porcine lungs were examined to optimize ICG concentrations and injection volumes. Transbronchial ICG injection (n=4) was assessed in comparison to a traditional transpleural approach (n=3), where after thoracotomy an ICG solution (100μL at 100μg/mL) was injected into the porcine right upper lobe for SN identification. For further translation into clinical use, transbronchial ICG injection prior to thoracotomy followed by NIR thoracoscopic imaging was validated (n=3). ENB was used for accurate targeting in two pigs with a pseudo-tumor.ResultsThe ICG fluorescence at 10 μg/mL was the brightest among various concentrations, unchanged by the distance between the thoracoscope and ICG solutions. Injected ICG of no more than 500μL showed a localized fluorescence area. All 7 pigs showed a bright paratracheal lymph node within 15 minutes post-injection, with persistent fluorescence for 60 minutes. The antecedent transbronchial ICG injection succeeded in SN identification in all 3 cases at the first thoracoscopic inspection within 20 minutes post-injection. The ENB system allowed accurate ICG injection surrounding the pseudo-tumors.ConclusionsENB-guided ICG injection followed by NIR thoracoscopy was technically feasible for SN mapping in the porcine lung. This promising platform may be translated into human clinical trials and is suited for MIS.

High Supracostal Percutaneous Nephrolithotomy Access: Assessing Safety in Access above the Eleventh Rib after Performing Preoperative Planning with Computed Tomography

Objective: To determine if supracostal renal access above the 11th rib during percutaneous nephrolithotomy (PCNL) is a safe option in carefully selected patients determined by preoperative computed tomography (CT) imaging. Patients and Methods: We retrospectively isolated 142 patients who underwent access above the eleventh rib during PCNL, which we term “high supracostal renal access.” We then compared these patients to 113 individuals who underwent access below the twelfth rib. Renal access was achieved by the operative surgeon with fluoroscopic guidance in conjunction with pre-operative computed tomography (CT) scan. Outcomes were compared. Results: Overall surgical outcomes were equivalent when comparing high supracostal versus subcostal access sites. As expected due to proximity, pleural complications occurred in 4% of the high supracostal group (n = 6) compared with 0% of the control (subcostal) group (p = 0.035). Of these six complications, three were managed conservatively with observation and two required cardio-thoracic intervention with video-assisted thoracoscopic pleural repair (1%). In the remaining case, the patient was preoperatively consented for placement of a thoracostomy tube, which was placed during the procedure, due to the difficult location of her upper pole stone and closely adjacent low-lying pleura, and the planned transpleural approach. Hospital stay was not significantly pro-longed between the high supracostal access and subcostal access groups, with an average length of stay of 2.2 ± 2.1 days and 2.0 ± 1.9 days (p = 0.59) respectively. Conclusions: Careful, systematic preoperative planning based on CT and fluoroscopic imaging allows for a confident understanding of a “safety zone” in placement and dilatation of renal access points during PCNL. We have shown that planned upper pole renal access above the 11th rib is achievable with acceptable morbidity and excellent success rates.

Percutaneous treatment of subarachnoid-pleural fistula with Onyx

Subarachnoid-pleural fistula is a well-described complication after anterior surgery for thoracic disc herniation, but is difficult to treat by means of traditional chest and lumbar drains due to interference by positive ventilation pressures that may keep the fistula open and prevent proper closure. Current treatment strategies include surgical repair, which is technically challenging, and noninvasive positive pressure ventilation, which can take several weeks to be effective. In this report, the authors describe a novel treatment for subarachnoid-pleural fistula using percutaneous obliteration with Onyx. Surgery for removal of a T7-8 disc herniation associated with ossification of the posterior longitudinal ligament was performed in a 56-year-old woman via an anterior transthoracic transpleural approach. Ten days after surgery, she presented with diplopia due to a subarachnoid-pleural fistula that was confirmed by CT myelography. Percutaneous injection of Onyx was performed under local anesthesia. Postprocedure CT showed complete obliteration of the fistula with no adverse events. A CT scan obtained 1 month later showed complete resolution of the pleural effusion. Neurological examination at 3 months postsurgery was normal. Clinical and radiological follow-up at 1 year showed complete recovery and no sign of fistula recurrence. Percutaneous treatment for subarachnoid-pleural fistula is an easy, safe, and effective strategy and can therefore be proposed as a first-line option for this challenging complication.

Operative Intercostal Chest Drain Is Not Required following Extrapleural or Transpleural Esophageal Atresia Repair

Approximately half of the United Kingdom patients undergoing esophageal atresia (OA) repair have an operative intercostal chest drain (ICD) placed (2008 British Association of Pediatric Surgeons Congenital Anomalies Surveillance Study data). We reviewed our experience of OA repairs to evaluate if an ICD placement is necessary. Patients with OA/distal tracheoesophageal fistula (TOF), treated between January 1990 and January 2010, were identified by retrospective review of a prospectively maintained electronic database and patient case notes. A total of 112 consecutive patients were identified, of whom 107 were included (73 male). Five were excluded as no case notes were available. Median birth weight was 2,597 g (range 924 to 4,245 g) and median gestational age was 38 weeks (27 to 41 weeks). Median age at discharge was 22 days (3 to 440 days) and median follow-up was 3.5 years (0 to 18 years). Patients were analyzed in two groups-group 1 (n = 73) had an extrapleural (EP) repair, of which 23 had a pleural breach and group 2 (n = 34) had a purposeful transpleural (TP) approach (surgeon preference). Eleven patients (10%) had an operative ICD, of which six patients were in group 1 and five in group 2. These 11 patients had an uncomplicated postoperative course and all operative ICD were removed within 48 hours of surgery. Of the 96 patients that did not have an operative ICD, only 2 (2%) required postoperative intervention. One patient, in group 2, had a postoperative ICD inserted for a simple pneumothorax at 12 hours and removed at 48 hours. The other patient, in group 1, had a clinically detected anastomotic leak after 48 hours and required operative repair. An operative ICD is not required following OA/distal TOF repair, whether the approach is EP or TP. ICD that were electively placed (in 10%) served no clinical purpose.

ANTERIOR DECOMPRESSIVE AND STABILIZING SURGERY FOR COMPLICATED THORACIC AND THORACOLUMBAR SPINAL INJURIES

Objective . To study the possibility of application of anterior decompressive and stabilizing operations in patients with complicated thoracic and thoracolumbar spine and spinal cord injury without prior posterior intervention. Material and Methods. Anterior decompressive and stabilizing operations in the thoracic and thoracolumbar spine were performed in 82 patients. Transpleural approach was used in 26 patients, transpleural transdiaphragmatic - in 46, and retroperitoneal subdiaphragmatic approach - in 10 patients. Decompression of the spinal cord was accomplished by means of subtotal resection of damaged vertebral bodies. The defect after removal of the fractured vertebral body was filled with a porous NiTi implant in 41 cases, with reinforced NiTi implant in 27 patients, and with the unique expandable NiTi implant - in 14 patients. The Vantage fixation plate added in all cases allowed manipulation of vertebrae along all axes in all directions. Results. A good regression of neurological symptoms was obtained in 28.0 % of patients, and satisfactory - in 48.9 %. Neurological deficit remained unchanged in 23.0 % of operated patients. No technique-related complications were registered. Reinforcement of porous implant with titanium rod signifi- cantly increased the interbody fusion solidity. Conclusion. Anterior decompressive and stabilizing surgery for thoracic and thoracolumbar spine and spinal cord injury provides complete decompression of the spinal cord, one-stage reduction, reclination of the spine and correction of its axis, and complete interbody fusion with porous titanium-nickel implants in combination with the Vantage fixation plate.

Late treatment of tuberculosis-associated kyphosis: literature review and experience from a SRS-GOP site

Spinal tuberculosis (TB) accounts for approximately half of all cases of musculoskeletal tuberculosis. Kyphosis is the rule in spinal tuberculosis and has potential detrimental effects on both the spinal cord and pulmonary function. Late-onset paraplegia is best avoided with the surgical correction of severe kyphosis, where at the same time anterior decompression of the cord is performed and the remnants of the tuberculosis-destroyed vertebral bodies are excised. Review of the literature on late surgical treatment of TB-associated kyphosis; description and comparative analysis of the different surgical techniques. Kyphosis can be corrected either at the acute stage or at the healed late stage of tuberculous infection. In the late stage, the stiffness of the spine and chronic lung disease are additional considerations for the surgical approach and technique. Contrary to the traditional anterior transpleural approach used in the acute spinal tuberculosis infection, extrapleural approaches, either antero-lateral or direct posterior, are favored in late treatment. The correction of deformity is only feasible with three-column osteotomies, and posterior vertebral column resection (PVCR) is the treatment of choice in extreme kyphosis. The prognosis of the neurologic deficit (late paraplegia) is dependent on the extent of gliosis of the spinal cord.

Thymectomy for thymoma and myasthenia gravis. A survey of current surgical practice in thymic disease amongst EACTS members

Thymic disorders, both oncological and non-oncological, are rare. Multi-institutional, randomized studies are currently not available. The Thymic Working Group of the European Association for Cardio-Thoracic Surgery (EACTS) decided to perform a survey aiming to estimate the extent and type of current surgical practice in thymic diseases. A questionnaire was addressed to the thoracic and cardio-thoracic members of the society, and the answers received from 114 participants were analysed. High-volume surgeons cooperate more frequently with a dedicated neurologist and anaesthesist (P = 0.04), determine more frequently neurological scores pre- and postoperatively (P = 0.02) and do not operate on thymic hyperplasia in stage I myasthenia gravis (MG) (P = 0.04). High-volume thymoma surgeons more often use a transpleural approach for stage I thymoma < 4 cm (P = 0.01), induction therapy (P = 0.05) and are more likely to have access to a tissue bank (P = 0.04). Both in thymoma and MG surgery, cooperative prospective studies seem to be feasible in dedicated thoracic surgical associations as EACTS.