Use Of Sternotomy Research Articles

PECULIARITIES OF CORONARY REVASCULARIZATIONS IN PATIENTS WITH DIAGNOSED LUNG CANCER AND CONCOMITANT ISCHEMIC HEART DISEASE

The object of the study: coronary revascularization in patients with malignant lung diseases and concomitant ischemic heart disease. The problem to be solved: selection of the optimal tactics for coronary bypass grafting simultaneously with lung resections. Main scientific results: an individual approach to the choice of tactics for carrying out simultaneous operations in patients with malignant lung diseases and concomitant ischemic heart disease is proposed. It has been shown that performing coronary artery bypass grafting simultaneously with lung resections, according to the proposed methods, allows minimizing surgical trauma and eliminating the influence of additional risk factors associated with cardiopulmonary bypass (CPB). The area of practical use of research results: surgical hospitals. An innovative technological product: methods for performing simultaneous coronary (artery) bypass grafting in patients with malignant lung diseases, based on the use of sternotomy, thoracotomy and mini-thoracotomy approaches. The area of application of an innovative technological product: clinical practice of performing simultaneous operations for combined pathology of the heart and lungs in medical institutions of a general surgical profile.

Volumetric Analysis is Useful for Predicting Use of Sternotomy During Retrosternal Thyroidectomy

Surgical removal is the recommended treatment for retrosternal goitre. This can be successfully achieved through a cervical incision in most cases, however occasionally a thoracic approach is required. Being able to predict the need for sternotomy would improve logistical efficiency, saving time and money, and allow patients to be better informed preoperatively. The aim of this study was to determine whether analysing thyroid volume on preoperative CT scans could help predict the use of sternotomy. To the best of our knowledge this is the first study investigating this. A retrospective study was conducted on 64 patients who underwent thyroidectomy for retrosternal goitre at the Golden Jubilee National Hospital, Scotland, between 2012-2016. Patient demographic information and pathological reports were obtained from databases. Preoperative CT scans were used for volumetric analysis. The total volume, the volume inferior to the level of the sternal notch (intrathoracic volume), and the anteroposterior diameter of the thoracic inlet were measured. An index of relative goitre size was calculated by dividing intrathoracic volume by thoracic inlet diameter. Mann-Whitney U tests and Fisher’s exact tests were used to analyse continuous and categorical variables respectively. Goitres were successfully removed by a cervical incision alone in 55 patients, while thoracic intervention was needed in 9 cases (13.3%). Intrathoracic volume (p=0.0091) and volumetric index (p=0.0033) were significantly larger in those requiring sternotomy. Total volume was not significantly different. All other variables measured were similar in both groups. Our results suggest that assessing intrathoracic volume of goitre is useful in predicting the need for sternotomy. However, it is not able to completely rule out thoracic intervention. The volumetric index is likely to be a better predictor than volume alone.

Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass

Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. Between May 1997 and January 2009, 102 patients (mean age, 63 years) underwent resection of renal tumor extending into the IVC by techniques developed to avoid sternotomy and CBP. The tumor thrombus in 12 patients (13%) extended into the supradiaphragmatic IVC and RA. Complete resection was successful through the transabdominal approach without CBP in all patients. Mean operative time was 8 hours 15 minutes. Estimated blood loss was 2960 mL, and a mean of 9 U of blood was transfused. Two patients died postoperatively, 1 on day 4 of arrhythmia and 1 on day 22 of multisystem organ failure. All discharged patients were alive at the last follow-up. Three patients had tumor recurrence and have been referred for adjuvant therapy. In select cases, renal cell carcinoma extending into the IVC to the intrapericardial level and RA can be resected without sternotomy, CBP, or DHCA.

Invited Commentary

During a 12-year period, the authors have treated 102 patients with renal cell carcinoma [1Ciancio G. Shirodkar S.P. Soloway M.S. Livingstone A.S. Barron M. Salerno T.A. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass.Ann Thorac Surg. 2010; 89: 505-511Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. The tumor thrombus in 12 patients extended into the supradiaphragmatic inferior vena cava and the right atrium (level 4 tumor). By combining the skill sets of liver transplantation, urologic oncology, cardiac surgery, and anesthesiology familiar with transesophageal echocardiography, these tumors were treated without sternotomy, cardiopulmonary bypass, or deep hypothermic circulatory arrest. An extended abdominal chevron incision was used. The inferior vena cava, liver, kidney, and right atrium were thoroughly mobilized to facilitate sequential clamping and tumor extraction. The surgical strategy is illustrated well in the figures. It is not surprising that the operations were time consuming (8 hours), with nearly 3 liters of blood loss and 9 units of transfusion per patient, despite use of a cell-saving device in 8 of the 12 patients. Obstruction of the hepatic veins with Budd-Chiari syndrome intensified bleeding problems. The postoperative intensive care unit stay was 7 days. There were 2 deaths: an 80-year-old patient died of a cardiac arrhythmia and another death was attributed to acute respiratory distress syndrome and multiple organ failure. Pulmonary metastases developed in 2 patients at 1 and 3 years after their operations, and local recurrence in the renal fossa was noted in 1 patient. These complications and deaths underscore the seriousness of the condition. The authors note a sobering 32% to 69% survival at 5 years in patients with tumor invading the inferior vena cava. This approach is novel, and some precautions seem warranted:1This technique will need intense preoperative planning based on imaging studies and pooling the skills of four physician teams involved in the procedure.2Findings during the assessment may suggest that cardiopulmonary bypass with hypothermia may be safer in view of caval or right atrial involvement.3If this technique is used, cell-saving devices and rapid infusion of shed blood will minimize blood requirements.4Great care is required in clamping the right atrium/inferior vena cava so that no tumor is left behind. Hand-held right atrial echocardiography scanning may be a useful adjunct and will, in addition, identify coronary sinus location.5Selective use of this new technique may be warranted in patients at high risk for cardiopulmonary bypass and possible hypothermic arrest. Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary BypassThe Annals of Thoracic SurgeryVol. 89Issue 2PreviewRenal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. Full-Text PDF

Pull-Through Esophagectomy Without Thoracotomy

Twenty patients with carcinoma of the hypopharynx, esophagus and thyroid underwent pull-through esophagectomy. Seventeen of them received combined resection of the larynx and trachea. Dissection of the lymph nodes at the upper mediastinum was performed in 11 patients by sternotomy. Seven patients received mediastinal tracheostomy after combined resection of the trachea and the larynx. Pull-through esophagectomy was followed by pharyngogastrostomy without thoracotomy via the posterior mediastinum. This technique is described in detail. Because there is no thoracotomy and ligation of the esophageal vessels is ensured, no pulmonary complications and no massive mediastinal hemorrhages occurred. There were no operative deaths. This operation offers excellent palliation and little morbidity. Moreover, the use of sternotomy and mediastinal tracheostomy for pull-through esophagectomy made it possible to dissect the upper mediastinal lymph nodes, and we could resect the affected trachea with certainty.