Resección de la primera costilla por videotoracoscopía en síndrome de Paget-Schroetter / Resection of the first rib by video thoracoscopy in Paget-Schroetter syndrome

Resumen El síndrome del opérculo torácico se refiere a una serie de signos y síntomas que se producen por la compresión del paquete vásculo-nervioso en la unión costo-clavicular. El síndrome de Paget-Schroetter (SPS) se define como la trombosis primaria, espontánea o de esfuerzo de la vena subclavia. Las vías de abordaje quirúrgicas tradicionales utilizadas para descomprimir el opérculo torácico son la trans axilar y las claviculares (supra e infra). El objetivo del estudio fue describir nuestra experiencia en la resección de la primera costilla por videotoracoscopía (VATS). Este es un estudio descriptivo observacional utilizando una base de datos prospectiva con análisis retrospectivo desde enero de 2017 a marzo de 2020. Se incluyeron 9 pacientes con diagnóstico de SPS en los que se resecó la primera costilla por VATS. En un paciente el procedimiento fue bilateral por presentar trombosis espontánea en ambas venas subclavias. De los 9, 6 eran mujeres. La edad media fue de 30.7 ± 10.7 años. La estadía hospitalaria media fue de 3.1 ± 0.5 días. Uno fue re-operado por hemotórax. No se detectaron recurrencias en el seguimiento a mediano-largo plazo. La resección de la primera costilla por VATS es un procedimiento seguro y factible. La misma, a diferencia de los abordajes tradicionales, puede ser resecada bajo visión directa de todos los elementos del opérculo torácico. Sin embargo, esta técnica requiere un manejo avanzado en cirugía toracoscópica.

Abstract Thoracic outlet syndrome (TOS) refers to a number of signs and symptoms that arise from compression of the neurovascular bundle at the costoclavicular junction. Paget-Schroetter syndrome is defined as the primary, spontaneous or effort thrombosis of the subclavian vein. The supraclavicular and trans-axillary approaches are currently the most commonly used for first rib resection. The aim of this article was to describe our experience in a minimally invasive approach (VATS) of first rib resection for primary venous thoracic outlet and the associated outcomes. This is a descriptive observational study using a retrospective analysis of a prospective database from January 2017 to March 2020. Nine patients underwent video thoracoscopic first rib resection due to PagetSchroetter syndrome (one bilateral procedure). Ten thoracoscopic first rib resections were performed. There were 6 female and 3 male patients, with a mean age of 30.7 ± 10.7 years. The mean length of hospital stay was 3.1 ± 0.5 days. No complications were recorded intraoperatively. One patient had to be re-operated because of hemothorax. There were no recurrences in a follow-up of at least 12 months. VATS resection of the first rib is a safe and feasible procedure and can be performed under direct vision of thoracic outlet elements. However, the technique requires experience with thoracoscopic surgery. The outcomes associated with our technique are comparable with the outcomes related to other current standards of care.

Comparative analysis of binding multi-fold rib graft, iliac bone graft and titanium mesh graft during surgery of tuberculosis of thoracic vertebra / 中国骨伤

OBJECTIVE@#To compare the clinical effects of three different methods of binding multi-fold rib graft, iliac bone graft and titanium mesh graft in tuberculosis of thoracic vertebra by approach of transverse rib process.@*METHODS@#A hundred and seven patients with tuberculosis of thoracic vertebra received surgical treatment from January 2010 to December 2016 were retrospectively analyzed. The patients were divided into three groups according different methods of bone graft. The surgical approach of the transverse rib process was used in all 107 patients, after thoroughly remove the necrotic tissue of tuberculosis, three different bone grafts were used respectively including iliac bone graft (36 cases, group A), binding multi-fold rib graft (35 cases, group B), titanium mesh bone graft (36 cases, group C). Perioperative indexes, the time required for bone graft during operation, intraoperation blood loss, the loss rate of the anterior edge of the lesion, Cobb angle, postoperative bone graft fusion time, spinal nerve recovery and Oswestry Disability Index were compared among three groups.@*RESULTS@#All the patients were followed up for 13 to 24 months, and the operation time required for bone graft was (23.2±4.1) min in group A, (23.8± 4.4)min in group B, and (25.5±4.2) min in group C, with no statistically significant difference among three groups (@*CONCLUSION@#The approach of transverse rib process for debridement of lesions can effectively treat tuberculosis of thoracic vertebra by binding multi-fold rib graft, iliac bone graft and titanium mesh graft, but binding multi-fold rib graft can effectively avoid iliac bone donor complications, and is an effective alternative to iliac bone graft, which is worth popularizing.

Posterior-only spinal fusion without rib head resection for treating type I neurofibromatosis with intra-canal rib head dislocation

OBJECTIVES: Patients with Type I neurofibromatosis scoliosis with intra-canal rib head protrusion are extremely rare. Current knowledge regarding the diagnosis and treatment for this situation are insufficient. The purpose of this study is to share our experience in the diagnosis and surgical treatments for such unique deformities. METHODS: Six patients with Type I neurofibromatosis scoliosis with rib head dislocation into the spinal canal were diagnosed at our institution. Posterior instrumentation and spinal fusion without intra-canal rib head resection via a posterior-only approach was performed for deformity correction and rib head extraction. The efficacy and outcomes of the surgery were evaluated by measurements before, immediately and 24 months after the surgery using the following parameters: coronal spinal Cobb angle, apex rotation and kyphosis of the spine and the intra-canal rib head position. Post-operative complications, surgery time and blood loss were also evaluated. RESULTS: Patients were followed up for at least 24 months post-operatively. The three dimensional spinal deformity was significantly improved and the intra-canal rib head was significantly extracted from the canal immediately after the surgery. At follow-up 24 months after surgery, solid fusions were achieved along the fusion segments, and the deformity corrections and rib head positions were well maintained. There were no surgery-related complications any time after the surgery. CONCLUSIONS: Systematic examinations are needed to identify patients with Type I neurofibromatosis scoliosis with rib head dislocation into the canal who can be treated by posterior-only spinal fusion without rib head resection. .

Afundamento costal estabilizado com suporte externo de metilmetacrilato em um felino / Ditching costal stabilized with external support of methylmethacrylate in a feline

O tórax instável ou afundamento costal acontece quando há fraturas múltiplas de pelo menos duas costelas consecutivas (CROWE et al., 2005). Nesse caso, durante a inspiração, o segmento fraturado, ao invés de expandir com o restante da caixa torácica, tende a penetrar no tórax. Subsequentemente, no momento da expiração, o conjunto instável tende a expansão (CROWE et al., 2005, FOSSUM, 2008). O tratamento inicial consiste em tornar o tórax estável, com uma pinça backhaus (AGUIAR, 2011). Posteriormente faz-se necessária a imobilização externa, que permitirá a adequada expansão torácica, sendo mantida por alguns dias até a estabilização do paciente. Para o tratamento cirúrgico recomenda-se a reconstrução anatômica das costelas fraturadas (CUNHA et al., 2009). O objetivo desse trabalho é demonstrar o tratamento da instabilidade costal com metilmetacrilato em felino, descrita por Coutinho et al. (2012).

Anatomical Study of Position of the Rib Head for Placing Anterior Vertebral Body Screws in a Chinese Population / Estudio Anatómico de la Posición de la Cabeza de la Costilla para Colocar Tornillos en la Zona Anterior del Cuerpo Vertebral en una Población China

Instrumentation of anterior vertebral body screws has become an important approach for treatment of unstable fracture or curvature of the spine, but little attention has been paid to the starting point of placing the screws and variability of the rib head position. We analyzed the variability of rib head position in a Chinese population in terms of the spinal canal and vertebral body using computed tomography (CT). Images from transverse CT scan of the T4-T12 vertebral bodies of 30 normal individuals were 3D reconstructed, and analyzed for measurement of parameters, which included: 1) distance between the left (or right) anterior border of the rib head and the posterior (or anterior) margin of the vertebral body [L(R )ARHP(A)VB], 2) left (or right) transverse dimension [L(R)TD], 3) left (or right) posterior (or anterior) safe angle [L(R)P(A)SA], and 4) distance between the inferior border of the left (or right) rib head and the superior (or inferior) end-plate in the sagittal plane [IL(R)RHS(I)EP]. The ARHPVB, PSA, and IRHIEP gradually decrease, but ARHAVB, TD, ASA, and IRHSEP gradually increase from T4 to T12, indicating that the position of the rib head changes from a more anterior position to a more posterior position and from a more superior position to a more inferior position as the number of the vertebra increases. Our study has provided comprehensive reference guide for accurate and safe instrumentation of vertebral body screws in treating related spine diseases.

La instrumentación del cuerpo anterior vertebral con tornillos ha sido una vía importante para el tratamiento de las fracturas inestables y curvaturas de la columna, pero se ha prestado poca atención a la zona de colocación de los tornillos y la variabilidad de la posición de la cabeza costal. Se analizó la variabilidad de la posición de la cabeza de la costilla en una población de China en relación al canal vertebral y cuerpo vertebral mediante tomografía computarizada (TC). Imágenes de cortes transversales de TC correspondientes a los cuerpos vertebrales T4-T12 de 30 individuos normales fueron reconstruidos tridimensionalmente, y se analizó la medida de algunos parámetros: 1) la distancia entre el margen anterior izquierdo (o derecho) de la cabeza de la costilla y el margen posterior (o anterior) del cuerpo vertebral [L(R)ARHP(A)VB], 2) Dimensión transversa izquierda (o derecha) [L(R)TD], 3) ángulo de seguridad izquierdo (o derecho) posterior (o anterior) [L(R)P(A)SA], y 4) la distancia entre el margen inferior de la cabeza de la costilla izquierda (o derecha) y la placa terminal superior (o inferior) en el plano sagital [IL(R)RHS(I)EP]. El ARHPVB, PSA, y IRHIEP disminuyeron gradualmente, pero ARHAVB, TD, ASA, y IRHSEP aumentaron gradualmente de T4 a T12, lo que indica que la posición de la cabeza de la costilla cambia desde una posición más anterior a una posición más posterior y de una posición más superior a una posición más inferior a medida que aumenta el número de vértebras. Nuestro estudio ha proporcionado completa guía de referencia para la instrumentación precisa y segura de tornillos en el cuerpo vertebral para el tratamiento de enfermedades relacionadas con la columna vertebral.

Temperature change in pig rib bone during implant site preparation by low-speed drilling

OBJECTIVES: The purpose of this study was to evaluate the temperature change during low-speed drilling using infrared thermography. MATERIAL AND METHODS: Pig ribs were used to provide cortical bone of a similar quality to human mandible. Heat production by three implant drill systems (two conventional drilling systems and one low-speed drilling system) was evaluated by measuring the bone temperature using infrared thermography. Each system had two different bur sizes. The drill systems used were twist drill (2.0 mm/2.5 mm), which establishes the direction of the implant, and finally a 3.0 mm-pilot drill. Thermal images were recorded using the IRI1001 system (Infrared Integrated Systems Ltd.). Baseline temperature was 31±1ºC. Measurements were repeated 10 times, and a static load of 10 kg was applied while drilling. Data were analyzed using descriptive statistics. Statistical analysis was conducted with two-way ANOVA. RESULTS AND CONCLUSIONS: Mean values (n=10 drill sequences) for maximum recorded temperature (Max TºC), change in temperature (ΔTºC) from baseline were as follows. The changes in temperature (ΔTºC) were 1.57ºC and 2.46ºC for the lowest and the highest values, respectively. Drilling at 50 rpm without irrigation did not produce overheating. There was no significant difference in heat production between the 3 implant drill systems (p>0.05). No implant drill system produced heat exceeding 47ºC, which is the critical temperature for bone necrosis during low-speed drilling. Low-speed drilling without irrigation could be used during implant site preparation.

Resección transaxilar de la primera costilla con apoyo endoscópico en el síndrome de salida de tórax: una opción quirúrgica segura / Endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe surgical option

Introducción: La resección transaxilar con apoyo endoscópico es una técnica quirúrgica novedosa en el manejo del síndrome de salida de tórax que permite identificar con seguridad el paquete vasculonervioso y las diferentes estructuras. Nuestro objetivo fue valorar los resultados de morbilidad y mortalidad del tratamiento quirúrgico en el síndrome de salida de tórax con esta técnica. Material y métodos: Estudio longitudinal prospectivo de 22 intervenciones quirúrgicas de resección transaxilar de la primera costilla, con apoyo endoscópico a pacientes con síndrome de salida de tórax, entre enero de 2000 y enero de 2009, en un hospital privado de la cuidad de Puebla, México. De ellos, 16 mujeres y seis hombres, con edad promedio de 35 años. Encontramos 16/22 (72.7 %) pacientes con síntomas neurológicos y 6/22 (27.3 %) con síntomas venosos; entre ellos, 2/22 (9.09 %) presentaban trombosis venosa de esfuerzo axilosubclavia. Resultados: Entre las 22 intervenciones encontramos bandas fibrosas en 8/22 pacientes (36.3 %): 1/22 (4.5 %) con una banda cervical tipo 1 y costilla cervical grado II, 1/22 (4.5 %) con banda cervical tipo 2 y costilla cervical grado I, 2/22 (9.09 %) con banda tipo 3, 1/22 (4.5 %) con banda tipo IV, 1/22 (4.5 %) con banda tipo V y 2/22 (9.09 %) con banda tipo VII y trombosis axilosubclavia. Después del procedimiento, 20/22 (90.9 %) pacientes manifestaron mejoría total y 2/22 (9.1 %), parestesias leves. No hubo complicaciones por lesiones nerviosas, vasculares o pleurales. Conclusiones: La técnica escrita provee un margen de seguridad amplio y mejora la visibilidad, disminuyendo las complicaciones quirúrgicas.

BACKGROUND: Endoscopic-assisted transaxillary first rib resection is a novel approach in the management of thoracic outlet syndrome (TOS) and allows us to safely identify the neurovascular package and different structures. Our main objective is to assess the results of morbidity and mortality of the surgical treatment in TOS with this technique. METHODS: We carried out a prospective, longitudinal study with 22 surgical interventions of transaxillary first rib resection with endoscopic support in patients with TOS from January 2000 to January 2009 in a private hospital located in Puebla, Mexico. There were 16 females and six males with a mean age of 35 years. We found 16/22 (72.7%) patients with neurological symptoms and 6/22 (27.3%) with venous symptoms; 2/22 (9.09%) patients had effort thrombosis of the axillary-subclavian vein. RESULTS: Of the 22 interventions, we found fibrous bands in 8/22 patients (36.3%); 1/22 (4.5%) with type 1 cervical band and cervical rib grade II, 1/22 (4.5%) with type 2 cervical band and cervical rib grade I, 2/22 (9.09%) with band type 3, 1/22 (4.5%) with band type IV, 1/22 (4.5%) with band type V and 2/22 (9.09%) with band type VII and axillary-subclavian thrombosis. After the procedure, 20/22 (90.9%) patients showed total symptom improvement and 2/22 (9.1%) patients had mild paresthesias. There were no complications from nerve, vascular or pleural damage. CONCLUSIONS: This technique provides an ample margin of safety and improves visibility, reducing surgical complications.

Surgical treatment of chest wall tuberculosis

Tuberculosis remains a formidable challenge to health care providers in developing countries and chest wall tuberculosis is a rare entity .Its clinical presentation may resemble a pyogenic abscess or chest wall tumor. There is still controversy regarding the diagnosis and treatment of chest wall tuberculosis. During a 10-year period [1998-2009], 12 cases with chest wall tuberculosis were managed by our team. Patients' medical records were retrospectively reviewed. After confirming the diagnosis by histopathological examination, patients underwent surgical management. There were 8 male and 4 female patients. Patients' age ranged from 4 to 60 years. Eight patients had a fluctuating abscess and 4 had a chest wall mass. Surgical procedure was drainage along with debridement in 6 patients, wide debridement along with rib resection in 2 patients and wide debridement along with chest wall resection and reconstruction in 4 patients. Recurrence of cold abscess and fistula formation were detected in 2 patients after a follow-up of 1 to 5 years. Outcome of patients with chest wall tuberculosis was good. chest wall tuberculosis mimics symptoms and signs of chest wall tumors or abscesses. The combination of symptoms and radiographic findings suggests the diagnosis of tuberculosis. Wide debridement and resection are shown to have lower rates of fistula formation, sinus formation and recurrence. Medical treatment must be started immediately after surgery

Surgical treatment of osteosarcoma in the ribs of a dog: a case report

A five-year-old male Doberman pinscher with an oval-shaped mass in the left side of thorax, respiratory distress, and an impairment of the use of the left forelimb was referred to the Faculty of Veterinary Medicine of ShahidChamran University in Ahvaz. Radiographs were taken. The abnormal mass was removed by radical surgery. Histopathological examination confirmed the occurrence of a well-differentiated canine osteosarcoma. The case was re-examined after approximately 15 months, which revealed a large mass in the left side and metastases in the right thoracic wall and lung. The decision was taken to euthanize the patient and a necropsy was performed. The recommended treatment for canine osteosarcoma is the removal of the primary tumor followed by adjuvant chemotherapy, but recurrence is common

Open renal approach: comparative analysis of sub-costal incision versus trans-costal incision with excision of 12[th] rib

To compare the outcome of sub-costal incision with trans-costal incision and 12[th] rib resection in the surgical approach for benign renal disease. It is a prospective, analytical, comparative study using randomized controlled trial [RCT], conducted at Fatima hospital-Baqai medical university [Karachi], from June 2005 to December 2008. In total 54 patients were enrolled in the study, who either underwent pyelolithotomy or nephrectomy via sub-costal [group A: 27 patients] or trans-costal incision [group B: 27 patients]. Incision time, duration of operation, postoperative pain, duration of hospital stay, and peroperative and postoperative complications were noted. Incision time and duration of operation were longer in group B patients [p-value 0.002 and 0.029 respectively]; pain perception was also markedly high in this group [p=0.001]. Total period to stay in hospital was marginally higher in group B [p=0.212]. Peroperative and postoperative complications were also slightly higher in group B patients [p-value 0.064 and 0.838 respectively]. Sub-costal renal approach provides adequate exposure, is quick, safe and less painful

Pulmonary complications of concave rib osteotomies in scoliotic patients

Operations such as anterior or posterior releases can be used to decrease the magnitude of spinal curves. Concave rib osteotomy is an example of posterior release. Pulmonary complications are the main complications of this operation and the major cause of related morbidities. In this study, the frequency of pulmonary complications was evaluated. Pulmonary complications of concave rib osteotomies were studied in a series of 14 patients at Sina Hospital in a 2-year period [2001-2003]. Eight patients were females and 6 were males. During the operation, 3 cases of pleural tear were detected and chest tubes were inserted for them. No cases of pneumothorax and only 1 case of asymptomatic pleural effusion were detected postoperatively. This operation is a simple procedure. If the valsalva maneuver is used and pleural tears are detected intraoperatively, pulmonary morbidities will not increase significantly

Lung functions after correction of scoliosis angle

In this study we evaluated lung volumes, volume changes relative to Cobb angle and correlation of volume changes with Cobb angle changes before and after the surgery. Eighteen non-smoker patients with idiopathic scoliosis were included in this descriptive observational study. Cobb angle, lung volume and flow were measured before and after the surgery. To assess height and weight changes during the follow-up period, we used the percent relative to normal [percent predicted] instead of absolute volumes. Eighteen of 30 selected patients were included. The mean follow-up period was 34.5 +/- 19.6 months. Dynamic volume changes of lung were: VC= -13.4 SD=8.6 [p < 0.005]; FVC=-9.22 SD=14 [p < 0.001]; FEV1=9.8 SD=15 [p < 0.001]. There was a weak correlation between the mean value of dynamic volume changes and the mean changes in Cobb angle after the surgery. There was a weak correlation between Cobb angle and dynamic volume of lung before the surgery. In this study there was a significant decrement of dynamic lung volumes after corrective surgery for thoracic curve scoliosis

Estudo anátomo-cirúrgico do cólon transverso do eqüino por acesso paralombar esquerdo / Anatomic and surgical study of the equine transverse colon from left paralombar aprouch

O cólon transverso é um estreitamento do canal alimentar, sujeito a sofrer processos obstrutivos. A ampliação do conhecimento sobre essa estrutura e adjacentes é de grande importância cirúrgica. Neste estudo foram utilizados 10 cadáveres de eqüinos de diferentes raças, idades e sexos, divididos em dois grupos de cinco. No primeiro grupo foi realizada uma incisão no 16º espaço intercostal esquerdo e posterior ressecção da 16ª costela. No segundo grupo a incisão foi feita sobre a 17ª costela com a remoção da mesma. Todas as estruturas identificadas foram registradas em fichas individuais, assim como a extensão exteriorizada do cólon transverso. Em todas os animais o cólon transverso foi totalmente visualizado e parcialmente exteriorizado, sendo que houve melhor manipulação e exteriorização no segundo grupo, além da maior facilidade no emprego da técnica, com a incisão sobre a costela a ser ressecada. Dessa forma, concluímos que o cólon transverso pode ser acessado pela fossa paralombar esquerda, sendo que a remoção da 17ª costela proporciona o melhor acesso para essa estrutura.

The transverse colon is a constriction of the bowel lumen, which canbe submitted to obstructive process. The knowledge enlargement about this structure and the adjacent ones has a great surgical importance. For such study, ten anatomic pieces, from equines corpses of different breed, age and sex, were used and divided in two groups. In the first group an incision was made in the left 16 intercostal space and farther resection of the 16 rib. In the second group an incision was made over the 17 rib, before its ressection. All the identified structures were registered into individual files, such as the extension of the exteriorized portion. In all of the studied pieces, the transverse colon was entirely visualized and partially exteriorized. However, we had better handling and exteriorization in the second group, as well as we noticed its technique was of easier execution. In accordance with the results, through this work is possible to conclude that the transverse colon can be approached by the left flank, and that the removal of the 17 rib provides a better access to the transverse colon.

A Comparative Study of Pericostal and Submuscular Bar Fixation Technique in the Nuss Procedure

We evaluated the safety and stability of the less-invasive submuscular bar fixation method in the Nuss procedure. One hundred and thirteen patients undergoing the Nuss procedure were divided into three groups according to the bar fixation technique employed. Group 1 consisted of 25 patients who had undergone bilateral pericostal bar fixation, group 2 consisted of 39 patients with unilateral pericostal one, and group 3 included 49 patients with bilateral submuscular one. The patients' age ranged from 2 to 25 yr, with an average of 7.2+/-5.67 yr. Bar dislocation occurred in 1 patient (4%) in Group 1, 2 patients (5.1%) in Group 2, and 1 patient (2.0%) in Group 3 (p=0.46). Hemothorax was noted in 2 patients (8%) in Group 1, 2 (5.1%) in Group 2, and none (0%) in Group 3 (Group 1 vs. Group 3, p=0.028). The mean operation time was shorter in Group 3 than Group 1 (50.1+/-21.00 in Group 3 vs. 67.2+/-33.07 min in Group 1, p=0.041). The submuscular bar fixation results in a decrease in technique-related complications and operation time and is associated with favorable results with regard to the prevention of bar dislodgement.

Management of pediatric temporomand bular joint ankylosis: use of costochondral rib graft with interpositiona, temporalis myofacial flap

The posttraumatic ankylosis of the temporomandibular joint [TMJ] is frequently seen in children in Pakistan. The factors which favour in the development of this condition are; the children exhibit much more liability to emergency management, greater difficulty in clinical and radiological examination, state of mixed dentition, faster rate of healing, non-availability of specialists and low socioeconomic status of the patient. Different autogenous and alloplastic interpositional materials have been attempted after the resection of the ankylotic bone to achieve desirable results. All patients were presented at Punjab Dental and Children Complex Hospitals Lahore. Twenty-three children [age 1 to 15years] with 28 joints underwent costochondral arthroplasty with interpositional temporalis myofacial flap, out of which 6 were of re-ankylosis after surgery at other centres. The costochondral graft was fixed by tripod screws with remaining ramus condylar unit. The surgery was planned after caref ul examination and final radiographic confirmation. The preoperative CT scan was also performed in few patients. The surgical protocol is used to achieve the desirable interincisal jaw opening [>30mm] that was also the postoperative criteria for successful surgery. Five patients with bilateral ankylosis were operated and one patient with additional ipsilateral coronoidectomy. Less than 30mm interincisal opening was considered as unsatisfactory jaw opening. The overall success rate was 96% with only one patient was observed with less than 30mm opening. The lateral and protrusive jaw movements were assessed as excellent, good and poor. The immediate postoperative complications were transient. The ankylosis develops mainly after damage to mandibular condyles or TMJ at a growing age. Results with the procedure were encouraging without noticeable complications during an average follow up of one year