1547 An Alternative Approach to High-Risk Resternotomy

Introduction Resternotomies are associated with substantial perioperative morbidity and mortality. Strategies described in literature mostly involve peripheral cannulation pre-sternotomy. Disadvantages of this technique relate to prolonged systemic heparinisation and cardiopulmonary bypass (CPB) time and the sequelae of hypothermic circulatory arrest. We describe a two-stage approach that potentially reduces the complications associated with high-risk resternotomy. Method 3 high-risk patients (from pre-operative CT images) were referred for redo complex aortic surgery. A right mini-thoracotomy incision was first made in the 4th or 5th intercostal space. The right lung was isolated and careful blunt dissection was carried out to mobilise the heart and great vessels attached to the sternum. Once these structures were free, thoracotomy incision was closed. A standard median sternotomy was then performed and central cannulation carried out after systemic heparinisation. Rest of the surgery was performed routinely. In one patient, aortic aneurysm was heavily adherent and attempts to mobilise it fully proved impossible. Resultantly, systemic heparinisation was administered and the patient was cannulated in the right superficial femoral artery and right atrium (via mini-thoracotomy). CPB was instituted and the patient cooled to 28 °C. Right superior pulmonary vein vent was introduced to prevent left ventricular distension from hypothermic ventricular fibrillation. Once the heart and aneurysm were decompressed on full CPB, complete mobilisation was performed safely. All 3 patients survived surgery without major complications. Conclusions Meticulous preoperative planning is key to management of high-risk resternotomy. We describe a novel technique which we believe minimises risk of morbidity and mortality in these complex cases.

Muscle-sparing thoracotomy: Anatomy and technique

The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes. However, subsequent study results have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.

Pre-emptive epidural analgesia for acute and chronic post-thoracotomy pain in adults: a systematic review and meta-analysis

Background and objectivesEpidural analgesia is the gold standard for post-thoracotomy pain management and can be started before or after surgical incision. This systematic review and meta-analysis investigated whether pre-emptive epidural analgesia before thoracotomy incision reduces acute and chronic post-thoracotomy pain in adults compared with epidural analgesia after incision.MethodsWe searched databases including MEDLINE, Embase, and CENTRAL for randomized controlled trials comparing epidural analgesia initiated before (pre-emptive group) and after (control group) thoracotomy incision in adults. The primary outcomes were the pain intensity during rest and coughing within 72 hours after surgery and the incidence of pain 1 to 6 months after surgery. Data were combined with random-effects meta-analyses. We rated the quality of evidence as high, moderate, low, and very low using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method.ResultsWe included 19 trials with 1062 participants involving 529 in the pre-emptive group and 533 in the control group. The pain intensity was significantly lower at rest within 72 hours after surgery (19 studies, n=1062) and during coughing within 48 hours after surgery (11 studies, n=638), and the incidence of pain was significantly lower 1 to 6 months after surgery (6 studies, n=276) in the pre-emptive group than in the control group. The quality of evidence was moderate or low in the primary outcomes.ConclusionsOur review provides low-quality evidence that pre-emptive epidural analgesia reduces the intensity of acute pain and the incidence of chronic pain after thoracotomy in adults.Protocol registration numberCRD42019131620.

Oesophageal GIST

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. Oesophageal GISTs are extremely uncommon, accounting for 0.7% of all GISTs, and their management is surrounded by some debate. We report a case of a 70-year-old man who was incidentally diagnosed with an oesophageal lesion on a 18F-fluorodeoxyglucose positron emission tomography. An endoscopic study revealed a non-obstructing 40 mm oesophageal lesion. Endoscopic ultrasound showed a well-circumscribed submucosal tumour on the middle oesophagus. Fine-needle aspiration was positive for CD117 and the overall features were of a GIST. After an initial thoracoscopic approach, the tumour was completely enucleated through a thoracotomy incision. The patient experienced no surgical complications and was discharged on day 4. Histopathology and immunohistochemical staining confirmed a low-risk GIST.

Hybrid closure of a large atrial septal defect using Occlutech Flex II septal occluder in a patient with interrupted inferior caval vein

We present a case of a 31-year-old male with a large atrial septal defect, who was found to have interrupted inferior caval vein with azygous continuation to the superior caval vein, which precluded transcutaneous closure by device. The defect was successfully closed with a 33 mm Occlutech Figula septal occluder using a sub-mammary small thoracotomy incision and per-atrial approach without using cardiopulmonary bypass. The patient was discharged home after 48 hours of procedure.

DOZ047.10: Acquired tracheoesophageal fistulas after esophageal atresia repair

Aim Tracheoesophageal fistula (TEF) recurrence is a frequent but challenging complication after esophageal atresia (EA) repair. Although most recurrent TEFs are commonly seen at the original fistula site, long new fistulas localized differently from the congenital TEF sites are called acquired TEFs (acq-TEF). Acq-TEFs are long new fistulas with unusual locations, including fistulas from the esophagus to anywhere on the airway such as the bronchus, trachea, or lung parenchyma. Herein, we aimed to discuss diagnostic and management challenges in different localizations of acquired TEF. Methods The medical records of patients admitted with acq-TEF in the last 5 years were retrospectively evaluated. The demographic features, admission complaints, physical and radiological findings, TEF localization and management were recorded. Results From 16 TEF recurrences, 4 TEFs were acquired fistulas. Admission age ranged from 3 months to 8 years. The female/male ratio was 2/2. The complaints were recurrent respiratory tract infections, choking, and coughing in all cases. Three of the cases had proximal EA + distal TEF; the other case was isolated EA. Primary repair was performed in 3 cases and colon interposition was performed in 1 case. Anastomotic leak and mediastinitis after initial operation were seen in 3 cases. Three acq-TEFs were to the cervical part of the trachea, one was from the colon conduit to the trachea, one was to right bronchus by passing through the intrathoracic abscess cavity, and one was directly to the right bronchus. In all cases the TEFs were shown in sine-esophagography and confirmed with bronchoscopy during operation. TEF was repaired by thoracotomy incision in 3 cases and callor incision in 1 case. The second acq-TEF of Case 1 was closed spontaneously. Muscle flap or pleura was placed between suture lines in all cases. All TEFs were confirmed to be closed with esophagography in all cases at postoperative period. Conclusion Acq-TEF is mostly seen secondary to local or diffuse mediastinitis. Besides its classical location of TEF, acq-TEFs may be seen at unusual rare localizations such as esophagus to right bronchus, esophagus to abscess cavity, and conduit to trachea. They cause both diagnostic and surgical challenge. Clinicians should be aware of these different localizations of Acq-TEFs in order to evaluate and manage these patients more comprehensively.

Antegrade Cardioplegia Decannulation Using the Cor-Knot System in Minimally Invasive Mitral Valve Surgery

A right mini-thoracotomy approach may be used for mitral valve repair without compromising clinical outcomes. Compared with conventional sternotomy, there is an increased distance to the cardiac structures from the mini-thoracotomy incision, which makes certain technical acts more demanding. One particular challenge is hemostasis at the antegrade cardioplegia cannula site. We propose a novel technique to remove an antegrade cardioplegia cannula using the COR-KNOT system. This technique negates the need for tying with a knot pusher and reduces the risk of aortic injury and troublesome bleeding.

Right Minithoracotomy Approach for Replacement of the Ascending Aorta, Hemiarch, and Aortic Valve

A minimally invasive right anterior thoracotomy approach is the preferred technique used at our institution for isolated aortic valve pathology. We have recently introduced more complex concomitant minimally invasive procedures through this access site. Here, we describe how we perform a replacement of the ascending aorta and aortic valve with and without the use of circulatory arrest through a 6-cm right minimally invasive thoracotomy incision.

Minimally Invasive Cardiac Surgery Using a 3D High-Definition Endoscopic System

We describe a minimally invasive heart surgery application of the EinsteinVision 2.0 3D high-definition endoscopic system (Aesculap AG, Tuttlingen, Germany) in an 81-year-old man with severe tricuspid valve insufficiency. Fourteen years ago, he underwent a Ross procedure followed by a DDD pacemaker implantation 4 years later for tachy-brady-syndrome. His biventricular function was normal. We recommended minimally invasive tricuspid valve repair. The application of the aformentioned endoscopic system was simple, and the impressive 3D depth view offered an easy and precise manipulation through a minimal thoracotomy incision, avoiding the need for a rib spreading retractor.