The modified transmanubrial approach in thyroid malignant tumors: an optimal and less invasive surgical option.

- We retrospectively evaluated a large series of patients (n: 15) underwent a modified transmanubrial approach for wide mediastinal resection in case of malignance thyroid mass - In fourteen cases, also with thyroid tumor involving the middle line. A bilateral mTMA was necessary to perform a cava vein resection. - No major postoperative and cutaneous/sternum complications were detected. - mTMA allows an optimal exposure of the upper thoracic inlet achieving a complete radical oncological resection of the tumor/lymph-node and a safety vascular/tracheal control. - As a limitation, the modified mTMA is anatomically more demanding and not familiar for most surgeons in comparison to sternotomy

Comparison of Cervical Sagittal Parameters Between Radiographs and Magnetic Resonance Images in Patients With Cervical Spondylotic Myelopathy

Study Design Observational study Objective As an important consideration of surgery, cervical sagittal balance is believed to be better assessed using standing radiograph than supine magnetic resonance imaging (MRI). However, few studies have researched this. Our study aimed to observe the correlations and differences in cervical sagittal parameters between radiograph and MRI in patients with cervical spondylotic myelopathy (CSM), and evaluate whether the change of position affects them. Methods We analyzed 84 patients, measuring Cobb angle (CA), T1 slope (T1S), neck tilt (NT), and thoracic inlet angle (TIA). Inter- and intra-parameter analyses were performed to identify any difference between standing radiograph and supine MRI. Statistical correlations and differences between the parameters were compared. Results There were excellent inter-observer agreement for each parameter (interclass correlation coefficient >.75), and significant differences were observed in each parameter between radiograph and magnetic resonance imaging ( P < .05). Strong correlations were noted between the same parameters in radiograph and MRI. Cobb angle, T1S, and neck tilt were significantly correlated with thoracic inlet angle on both radiograph and MRI, and CA was significantly correlated with T1S on both radiograph and MRI ( r: −1.0 to −.5 or .5 to 1.0). Conclusion Supine MRI obviously underestimated the value of CA, T1S, and TIA. Therefore, standing cervical radiographs should be obtained in CSM patients to assess and determine surgical strategy, not only supine MRI. Moreover, we observed that NT and TIA were not constant morphological parameters.

Ideal Anatomical Landmark Points for Thoracic Esophagus Segmentation in the Chinese Population

Introduction: The standards of esophagus segmentation remain different between the Japan Esophageal Society (JES) guideline and the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) guideline. This study aimed to present variations in the location of intrathoracic esophageal adjacent anatomical landmarks (EAALs) and determine an appropriate method for segmenting the thoracic esophagus based on the relatively fixed EAALs.Patients and Methods: The distances from the upper incisors to the upper border of the esophageal hiatus, lower border of the inferior pulmonary vein (LPV), tracheal bifurcation, lower border of the azygous vein (LAV), and thoracic inlet were measured in the patients undergoing thoracic surgery. The median distances between the EAALs and the specified starting points, as well as reference value ranges and ratios, were obtained. The variation coefficients of distances and ratios from certain starting points to different EAALs were calculated and compared to determine the relatively fixed landmarks.Results: This study included 305 patients. The average distance from the upper incisors to the upper border of the cardia, the midpoint between the tracheal bifurcation and esophageal hiatus (MTBEH), LPV, LAV, tracheal bifurcation, and thoracic inlet were 41.6, 35.3, 34.8, 29.4, 29.5, and 20.3 cm, respectively. The distances from the upper incisors or thoracic inlet to any intrathoracic EAALs in men were higher than in women. In addition, the height, weight, and body mass index (BMI) were correlated with the distances. The ratio of the distance between the upper incisors and tracheal bifurcation to the distance between the upper incisors and upper border of the cardia and the ratio of the distance between the thoracic inlet and tracheal bifurcation to the distance between the thoracic inlet and upper border of the cardia possessed relatively smaller coefficients of variation.Conclusion: The distances from the EAALs to the upper incisors vary with height, weight, BMI, and gender. Compared with distance, the ratios are more suitable for esophagus segmentation. Tracheal bifurcation and MTBEH are ideal EAALs for thoracic esophagus segmentation, and this is consistent with the JES guideline recommendation.

Cervicothoracic lipoblastoma: three case reports and review of literature

Background Lipoblastoma is a rare benign mesenchymal tumor of embryonal fat affecting mainly children below 3 years of age. It presents usually as a painless rapidly growing soft lobular mass in the extremities, trunk, and less frequently in the head-neck region. Preoperative imaging is used to assess the extent of disease and aid surgical planning. Complete surgical excision without injury to surrounding vital structures is the treatment of choice. Case presentation We report three interesting lipoblastoma cases: mediastinal lipoblastoma with airway compression and ipsilateral diaphragmatic eventration, neck lipoblastoma with intrathoracic extension, and huge thoracic inlet lipoblastoma with compression of common carotid and Lt subclavian arteries, brachial plexus, and ipsilateral diaphragmatic eventration. Complete excision of lipoblastoma mass was done via neck incision in two cases, and the third case required thoracoscopic excision of intrathoracic remnant 6 months later. All three patients had an excellent outcome. Conclusions Management of cervicothoracic lipoblastoma is a surgical challenge due to the potential for rapid growth and extension to different fascial planes; however, successful excision can be achieved via a neck approach. Complete surgical excision is essential to prevent local recurrence and improve the outcome.

The neck

The neck occupies the space between the clavicles and thoracic inlet inferiorly, to the base of the skull and inferior border of the mandible superiorly. The cervical part of the vertebral column provides the support for the skull above and strength and movement to the neck proper. The anterior neck provides passage for the major neurovascular supply to and drainage from the head, neck and intracranial region, transmits the upper aerodigestive tract and houses the thyroid and parathyroid glands. In the posterior neck a large mass of extensor musculature is situated posterior to the cervical vertebrae. Cranial nerves nine through twelve descend into the neck: nine (glossopharyngeal) and twelve (hypoglossal) meander towards the oropharynx and tongue, respectively; cranial nerve eleven (accessory) deflects backwards to supply the sternocleidomastoid and trapezius muscles whilst the tenth cranial nerve (vagus) wanders inferiorly within the carotid sheath between and posterior to the common carotid artery and internal jugular vein, before disappearing into the thoracic and abdominal cavities.

Biomechanical aspects of the initial stability of instrumental fixation in the treatment of subaxial cervical dislocations: an experimental study

Objective. To study the influence of thoracic inlet angle (TIA) and the fracture of the articular process on the initial strength of the fixation of the spinal segment during its anterior and circular instrumental surgical stabilization in an experiment on a model of the lower cervical spinal segment.Material and Methods. The material of the study was assembled models of C6–C7 spinal segments made using addictive technologies by 3D printing. After preliminary instrumentation, spinal segments were installed on the stand testing machine using specially manufactured equipment. A metered axial load simulating the native one was applied along the axis of the parameters SVA COG–C7 and C2–C7 SVA, which values were close to the value of 20 mm, at a rate of 1 mm/min until the shear strain was reached. The system’s resistance to displacement was measured, and the resulting load was evaluated. Four study groups were formed depending on the modeling of the T1 slope parameter, the integrity of the facets, and the type of instrumentation. Three tests were conducted in each group. The graphical curves were analyzed, and the values of the parameters of the neutral and elastic zones, the yield point, time to yield point, and the value of the applied load for the implementation of shear displacement were recorded. The data were subjected to comparative analysis.Results. In Group 1, anterior shear displacement of the C6 vertebra could not be induced in all series. In groups 2, 3, and 4 a shear displacement of ≥4 mm was noted in all series. In Group 3 where a fracture of the articular process was additionally modeled, the average value of the yield point was 423.5 ± 46.8 N. Elastic zone, the time to the onset of the yield point, the time at the end point or at a shear of C6 ≥4 mm did not differ significantly. In Group 4, a translational displacement of ≥4 mm was observed, though the average yield point was 1536.0 ± 40.0 N.Conclusion. The direction of the load applied to the fixed spinal segment, as well as the presence of damage to the articular processes, play a crucial role in maintaining resistance to shear deformation of the spinal segment during its instrumental stabilization. At high values of TIA (T1 slope) and the presence of fractures of the articular processes, the isolated anterior stabilization is less effective, circular fixation of 360° under these conditions gives a high initial stability to the spinal segment.

29 SIZE OF THE THORACIC INLET SPACE AS A PREDICTOR OF CERVICAL ANASTOMOTIC LEAK AFTER RETROSTERNAL RECONSTRUCTION FOLLOWING ESOPHAGECTOMY

Although anastomotic leak is a common postoperative complication following an esophagectomy, it is not well known whether anatomical factors increase the risk for anastomotic leak after the procedure. The purpose of this study was to clarify whether a narrow thoracic inlet is an independent predictor of cervical anastomotic leak after retrosternal reconstruction following esophagectomy. Methods A total of 212 patients who underwent esophagectomy with gastric conduit retrosternal reconstruction between January 2013 and March 2019 were included in this study. Computed tomography was used to measure the thickness of the sternum (TS), the thickness of the clavicle (TC), the interclavicular distance, the sternum-trachea distance (STD), the sternum-vertebral body distance (SVD), and the sternum-trachea distance/sternum-vertebral body distance ratio (STD/SVD ratio). The correlation between various factors was analyzed using Spearman’s correlation coefficient. Tree-based analysis was performed to define cutoff values. Multivariate logistic regression was used to analyze the association between various predictors and anastomotic leak. Results Anastomotic leak occurred in 26 patients (12.26%). Tree-based analysis identified an optimal TS cutoff value of 20.84 mm, a TC cutoff value of 23.63, and a STD/SVD ratio cut off value of 0.2138 to predict anastomotic leak. There were significant associations between the STD, STD/SVD ratio and thoracic inlet area (STD × ICD). According to multivariate analysis, STD/SVD ratio, TS, TC, and diabetes mellitus were significantly associated with increased incidence of anastomotic leak. Conclusion STD/SVD ratio, TS, TC, and diabetes mellitus were associated with higher rates of cervical anastomotic leak after retrosternal gastric conduit reconstruction following esophagectomy. In patients with a small thoracic inlet, posterior mediastinal reconstruction and intrathoracic anastomosis should be considered.

Retrosternal goitre and its management

Retrosternal goiter (RSG) is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Retrosternal goitre is defined as a goitre with a portion of its mass ≥ 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy. Retrospective study, teaching hospital-based. Retrospective analysis of 687 thyroidectomies performed between 2008 and 2019. The 47 (6.84 %) patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment. There were 47 patients (6.84 %) with RSG, [ 34 females (72.34%), 13 males (27.66%)] (mean age: 52 years, range: 34-76)], out of 687 thyroidectomies, in a 14 -year period. The most common presentation was neck swelling (68%), followed by respiratory symptoms (46.8%) and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 43 (91.5 %) of the cases, only 4 cases (8.5 %) required sternotomy, (residual thyroid in mediastinum after cervical approach in one case and due to very large thyroid reaching the main bronchial bifurcation in the other three). The final histological diagnosis revealed malignancy in 8.5 % of the thyroid specimens. There was no mortality and minor complications occurred in nine patients (19.1%). The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy. Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the extent of the goitre to or below the tracheae carina. If retrosternal goitre thyroidectomy is performed by a skilled surgical team, familiar with its unique pitfalls, the assistance of a thoracic surgeon may be required only in a few selected cases

Kompressionssyndrome der supraaortalen Gefäße

ZusammenfassungVaskuläre Kompressionssyndrome betreffen meist die obere Thoraxapertur, häufig begleitet von einer nervalen Symptomatik, und werden zusammengefasst als Thoracic-outlet- (TOS) und, falls eine isolierte venöse Kompression im Vordergrund steht, als Thoracic-inlet-Syndrom (TIS) bezeichnet. Diagnostik und Therapie sind oft schwierig. Fehlende vaskuläre und neurogene Veränderungen indizieren als erstes meist eine konservative Therapie. Der embolische Verschluss der Armarterien bei jüngeren Patienten sowie eine erfolglose oder von Komplikationen gefolgte Embolektomie ohne offensichtliche andere Risikofaktoren sollten unbedingt an ein TOS denken lassen. TOS-Operationen sind technisch nicht einfach und sollten erfahrenen Fachabteilungen vorbehalten bleiben. Die richtige Patientenselektion ist mitentscheidend für ein erfolgreiches Ergebnis. Implantationen von Stents im Bereich des Schultergürtels sollten bei Kompressionssyndromen vermieden werden. Eine weitere Möglichkeit der supraaortalen Kompression ist durch eine A. lusoria möglich.