Treatment of traumatic rib fractures: an overview of current evidence and future perspectives.

Operative management of rib fractures has gained significant popularity over the last years, however, it remains a controversial topic, due to the substantial heterogeneity among rib fracture patients with considerable differences in epidemiology. Hence, the present narrative review aims to provide an overview of the treatment and (long-term) outcomes of rib fractures, with an emphasis on the surgical treatment. Nowadays, computed tomography (CT) has been shown to be most practical and sensitive for detecting rib fractures, of which up to 50% is missed on other imaging modalities. Non-operative treatment by patient-tailored multimodal pain management remains the cornerstone. Still, in the presence of-amidst others-chest wall instability or displaced fractures with physiologic derangements, operative treatment is indicated and should be performed within 72 hours after injury. Here, traumatic brain injury (TBI) and pulmonary contusion are no strict contra-indications, while plate osteosynthesis is considered the standard mode for surgical stabilization. To date, surgical stabilization of rib fractures (SSRF) only benefits selected groups of patients, awaiting results of ongoing studies. Future directions may include the sole use of percutaneous cryoablation of the intercostal nerves as part of conservative management, as well as the application of three-dimensional (3D) printing and use of bio-absorbable materials in the surgical treatment of rib fractures.

lnsights into Adjuvant Systemic Treatment Selection for Patients with Stage III Melanoma: Data from the Dutch Cancer Registry.

BACKGROUND: Patient demographics and shared decision making might influence the choice of adjuvant therapy for stage III melanoma. OBJECTIVE: To identify factors for treatment selection of patients diagnosed with stage III melanoma to better understand current treatment decisions and improve further treatment counseling. PATIENTS AND METHODS: Data from 2007 patients diagnosed with stage III melanoma, between December 2018 and 2021, sourced from the Dutch Cancer Registry, were analyzed. RESULTS: Among the cohort, 48.7% received no therapy, 45.8% received checkpoint inhibition, and 5.5% received targeted therapy (TT). Patients foregoing therapy were significantly older [67.0 years (range 53.0-77.0) vs. 62.0 year (range 52.0-72.0)], had poorer performance scores (PS), and higher Charlson Comorbidity Index scores compared to those receiving therapy (p < 0.001). Patients undergoing therapy had significantly higher median Breslow thickness (3.3 mm vs. 2.2 mm) and higher prevalence of ulceration (49.9% vs. 38.1%). Those with connective tissue disease and/or congestive heart disease were more likely to receive TT [odds ration (OR) 8.1; 95% confidence interval (CI) 1.7-37.6 and OR 9.3; 95% CI 1.2-72.2, respectively]. Median treatment time among strata for disease recurrence was 4.26 months (3.69-4.82) for immunotherapy and 3.1 months (0.85-5.36) for TT (p = 0.298). Patients who developed recurrent disease were equal across treatment types (p = 0.656). The number of patients with grade 3 complications was different for each treatment type [immunotherapy: 17.8% vs. TT: 37.3% (p < 0.001)]. CONCLUSIONS: Age, PS, and Breslow thickness seem to influence adjuvant treatment decisions. Clinicians' preference for immunotherapy might play a role in counseling BRAF-positive patients for adjuvant therapy, this however, cannot be confirmed in this dataset. Overall, only a small proportion of patients completed adjuvant treatment.

Evaluating three-dimensional lung reconstructions for thoracoscopic lung resections using open-source software: a pilot study.

Background: Preoperative three-dimensional (3D) lung reconstructions can reduce intraoperative blood loss, conversion rate, and operation duration. These 3D reconstructions are predominantly provided by commercial expensive products, hence we aimed to assess the usability and performance of preoperative 3D lung reconstructions created with open-source software. Methods: Patients were invited to participate in this prospective pilot study if they were planned for uniportal video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy between January and February 2023. Participants were excluded if a two-dimensional (2D) late-arterial-phase computed tomography (CT) scan contained motion artifacts, another surgical procedure was performed, or the surgery was canceled. After informed consent was obtained, 3D lung reconstructions were constructed using open-source 3D Slicer software. The system usability score (SUS) questionnaire assessed the usability of these reconstructions, whilst performance was evaluated based on anatomical validity compared to prior 2D CT assessment as well as operative findings. Descriptive statistics were reported. Results: Thirteen patients were included, of whom one underwent a segmentectomy. Eighty-three percent of the 3D lung reconstructions scored above average (SUS >68). Compared to 2D CT scans, 38% of lung nodule segmental locations were detected more accurately through 3D lung reconstructions. Furthermore, 3D lung reconstructions revealed anatomical variations in 62%, which were not recognized on 2D CT scans, and provided surgeons with insights that would change the procedure and/or transection planes in 62%. One 3D lung reconstruction failed to demonstrate an intraoperative recognized segmental pulmonary artery (A6) branch. Conclusions: Three-dimensional lung reconstructions created with open-source software were usable and effective for uniportal VATS anatomical resections. Trial Registration: ClinicalTrials.gov/NCT06132607.

Bupivacaine pleural effusion mimicking a hemothorax after a thoracoscopic microdiscectomy with epidural anesthesia.

PURPOSE: Post-operative pain after video-assisted thoracoscopic surgery is often treated using thoracic epidural analgesics or thoracic paravertebral analgesics. This article describes a case where a thoracic disc herniation is treated with a thoracoscopic microdiscectomy with post-operative thoracic epidural analgesics. The patient developed a bupivacaine pleural effusion which mimicked a hemothorax on computed tomography (CT). METHODS: The presence of bupivacaine in the pleural effusion was confirmed using a high performance liquid chromatography method. RESULTS: The patient underwent a re-exploration to relieve the pleural effusion. The patient showed a long-term recovery similar to what can be expected from an uncomplicated thoracoscopic microdiscectomy. CONCLUSION: A pleural effusion may occur when thoracic epidural analgesics are used in patents with a corridor between the pleural cavity and epidural space.

Gastrointestinal Tolerance of Formula-Fed Infants During the Immediate Postnatal Period in Saudi Arabia: An Observational Study.

Objective. Feeding intolerance during the early postnatal period can be distressing for families. To assess this, infants (n = 150) of mothers who had previously decided to exclusively or partially formula feed were enrolled ≤24 hours after birth. Methods. Infants were fed with a single ready-to-feed, 100% partially hydrolyzed whey protein-based formula until discharge, in accordance with standard hospital practice. Parents recorded daily the presence/severity of gastrointestinal (GI) symptoms/behaviors, rated from 0 (never) to 5 (always). A validated questionnaire was completed at discharge to evaluate symptoms of GI discomfort; scores can range from 0 to ~140 (lower scores indicate fewer symptoms). Results. Mean ± SD daily scores ranged from 0.12 ± 0.40 (fussiness/irritability) to 1.26 ± 0.90 (spitting up), indicating that GI symptoms/behaviors occurred, on average, "never" or "almost never." Mean GI discomfort scores were also very low (9.9 ± 7.4). Conclusion. These results indicate that the ready-to-feed formula was very well accepted and well tolerated during this period among healthy newborns in Saudi Arabia.

Management of soft tissue sarcomas of the chest wall: a comprehensive overview.

Sarcomas of the chest wall are rare and their current treatment regimen is diverse and complex due to the heterogeneity of these tumors as well as the variations in tumor location and extent. They only account for 0.04% of newly diagnosed cancers of whom about 45% comprise soft tissue sarcomas. Larger cohort studies are scarce and often focus on one specific treatment item. We therefore aim to provide helicopter view for clinicians treating patients with sarcomas of the chest wall, focusing mainly on soft tissue sarcomas. This overview includes the value of neoadjuvant systemic or radiotherapy, surgical resection, approaches for thoracic wall reconstruction, and the need for follow-up. Provided the heterogeneity and relative rarity, we recommend that treatment decisions in soft tissue sarcoma of the chest wall are discussed in a multidisciplinary tumor board at a reference sarcoma center or within sarcoma networks to ensure personalized, rational decision making. A surgical oncologist specialized in sarcoma surgery is crucial, and for extensive resections involving the thoracic cavity we recommend involvement of a thoracic surgeon. In addition, a specialized medical- and radiation oncologist as well as a plastic surgeon is required to ensure the best multimodality treatment plan to optimize patient outcome.

Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax.

BACKGROUND: Multiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS. METHODS: From January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes). RESULTS: A total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes. CONCLUSIONS: This study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.

Scapula alata, a rare complication after minimally invasive repair of pectus excavatum.

A male patient in his early 30s underwent minimally invasive repair of pectus excavatum. According to standard Nuss bar procedure, a 30-degree thoracoscope was introduced through a right midaxillary 10 mm trocar in the 4th intercostal space. Two bars and five stabilisers were placed in a retromuscular position. After discharge, the patient experienced right upper back pain requiring prolonged opioid usage for three months and right scapular winging limiting functional activities. After conservative treatment with physiotherapy for 11 months, the patient still suffered from residual scapula alata with pain and muscle weakness. On suspicion of long thoracic nerve neuropraxia related to the thoracoscope placement, an electromyogram was conducted 16 months following surgery, revealing mild polyphasic potentials of the serratus anterior muscle without abnormal muscle unit action potential. After extended conservative therapy for another year, physical examination 28 months after surgery showed almost complete resolution of scapular winging.

The use of intravenous indocyanine green in minimally invasive segmental lung resections: a systematic review.

Background: To identify intersegmental planes (ISPs) in video/robot-assisted thoracoscopic segmentectomies, indocyanine green (ICG) is commonly used. The aim of this systematic review is to evaluate the efficacy of intravenous ICG in the identification of ISP. Methods: A systematic search was performed. Studies evaluating patients who underwent a video/robot-assisted thoracoscopic segmentectomy using intravenous ICG were included. The primary outcome measure was the frequency and percentage of patients in whom the ISP was adequately visualized. Secondary outcomes encompassed the ICG dose, time to visualization, time to maximum ICG visualization, time to disappearance of ICG effect and adverse reactions to ICG. Results: Eighteen studies were included for systematic review, enrolling a total of 1,090 patients. Irrespective of the injected dose, intravenous ICG identified the ISP in 94% of the cases (range, 30-100%). Overall, there was a considerable amount of heterogeneity regarding the injected dose of ICG (range, 5-25 mg or 0.05-0.5 mg/kg). The mean time before first effect of ICG was visible ranged from 10 to 40 seconds. The mean total time of ICG visibility ranged from 90 to 140 seconds after a bolus injection and was 170 seconds after continuous infusion. No adverse reactions were reported. Conclusions: After administration of intravenous ICG, visualization of the ISP is successful in up to 94% of cases, even after administration of a low dose (0.05 mg/kg) of ICG. The use of intravenous ICG is safe with no reported adverse effects in the immediate peri-operative period.

Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial).

INTRODUCTION: Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure. METHODS AND ANALYSIS: This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs. ETHICS AND DISSEMINATION: This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER: NCT05731973.

Pectus excavatum and carinatum: a narrative review of epidemiology, etiopathogenesis, clinical features, and classification.

Background and Objective: A wide variety of congenital chest wall deformities that manifest in infants, children and adolescents exists, among which are pectus excavatum and pectus carinatum. Numerous studies have been conducted over the years aiming to better understand these deformities. This report provides a brief overview of what is currently known about the epidemiology, etiopathogenesis, clinical presentation, and classification of these deformities, and highlights the gaps in knowledge. Methods: A search was conducted for all the above-described domains in the PubMed and Embase databases. Key Content and Findings: A total of 147 articles were included in this narrative review. Estimation of the true incidence and prevalence of pectus excavatum and carinatum is challenging due to lacking consensus on a definition of both deformities. Nowadays, several theories for the development of pectus excavatum and carinatum have been suggested which focus on intrinsic or extrinsic pathogenic factors, with the leading hypothesis focusing on overgrowth or growth disturbance of costal cartilages. Furthermore, genetic predisposition to the deformities is likely to exist. Pectus excavatum is frequently associated with cardiopulmonary symptoms, while pectus carinatum patients mostly present with cosmetic complaints. Both deformities are classified based on the shape or severity of the deformity. However, each classification system has its limitations. Conclusions: Substantial progress has been made in the past few decades in understanding the development and symptomatology of pectus excavatum and carinatum. Current hypotheses on the etiology of the deformities should be confirmed by biomedical and genetic studies. For clinical purposes, the establishment of a clear definition and classification system for both deformities based on objective morphologic features is eagerly anticipated.

Advancements in preoperative imaging of pectus excavatum: a comprehensive review.

Pectus excavatum, the most common pectus deformity, varies in severity and has been associated with cardiopulmonary impairment and psychological distress. Since its initial documentation, a multitude of imaging techniques for preoperative evaluation (i.e., diagnosis, severity classification, functional assessment, and surgical planning) have been reported. Conventional imaging techniques encompass computed tomography (CT), chest radiography, magnetic resonance imaging (MRI), echocardiography and medical photography, while three dimensional (3D) optical surface imaging is a promising emerging technique in the preoperative assessment of pectus excavatum. This narrative review explores the current insights and advancements of these imaging modalities. CT imaging allows for the calculation of pectus indices and evaluation of cardiac compression and displacement. Recent developments focus on automated calculations, minimizing radiation exposure and improving surgical planning. Chest radiography offers a radiation-reducing alternative for pectus index measurement, but is unsuitable for disproportionally asymmetric chest deformations. MRI is a radiation-free imaging method, and allows for the calculation of pectus indices as well as the assessment of cardiac function. Real-time MRI provides dynamic insights, while exercise MRI shows promise for comprehensive evaluation of cardiac function but requires additional developments. Using echocardiography, structural cardiac changes can be identified, but its use in evaluating cardiac function in pectus excavatum patients is limited. Medical photography combined with caliper measurements complements other imaging methods for qualitative and quantitative documentation of pectus excavatum. Emerging as an innovative technique, 3D optical surface imaging offers a rapid, radiation-free assessment of the deformity which correlates with conventional pectus indices. Potential applications include quantifying other morphological features and predicting cardiac compression. However, standardization and validation are needed for its widespread use. This review provides an overview of preoperative imaging of pectus excavatum, highlighting the current developments in conventional methods and the potential of the emerging 3D optical surface imaging technique. These advancements hold promise for the future of the assessment and surgical planning of pectus excavatum.

Impact of low dose superparamagnetic iron oxide tracer for sentinel node biopsy in breast conserving treatment on susceptibility artefacts on magnetic resonance imaging and contrast enhanced mammography.

BACKGROUND: Residual particles of superparamagnetic iron oxide (SPIO) tracer, used for sentinel node biopsy, cause susceptibility artefacts on breast Magnetic Resonance Imaging (MRI). We investigated the impact of these artefacts on the imaging quality of MRI and explored whether contrast-enhanced mammography (CEM) could be an alternative in the follow-up of breast cancer patients. MATERIALS AND METHODS: Data on patients' characteristics, injection site, presence, size (mm) of artefacts on full-field digital mammography (FFDM)/CEM, MRI after 1 ml SPIO was recorded. Image quality scored by two breast radiologists using a 4-point Likert system: 0: no artefacts 1: good diagnostic quality 2: impaired but still readable 3: hampered clinical assessment. Continuous variables reported as means and standard deviations (SD), categorical variables as count and percentage. RESULTS: On FFDM/CEM, performed 13 months postoperatively, no iron SPIO particles were detected, with a Likert score of 0. In all MRI (100%) images, executed at 16.6 months after SPIO injection, susceptibility artefacts at the injection sites i.e., retroareolair and lateral quadrant were observed with a mean size of 41.9 ± 9.8 mm (SD) by observer 1, and 44.8 ± 12.5 mm (SD) by observer 2, independent of the injection site. Both observers scored a Likert score of 2: locally impaired on all MRI images and sequences. CONCLUSIONS: Even 1 ml SPIO tracer used for sentinel node procedure impairs the evaluation of breast MRI at the tracer injection site beyond one year of follow-up. No impairment was observed on FFDM/CEM, suggesting that CEM might be a reliable alternative to breast MRI if required.

The Role of Magnetic Resonance Imaging in the Preoperative Staging and Treatment of Invasive Lobular Carcinoma.

INTRODUCTION: Invasive lobular carcinoma (ILC) is known for its diffuse growth pattern and its associated challenges in diagnosing. Magnetic resonance imaging (MRI) is the most accurate imaging modality and might aid in improving preoperative staging compared to full field digital mammography (FFDM) and ultrasound (US), however current literature is inconsistent. The aim of this paper is to evaluate the accuracy of MRI staging compared to FFDM/US and pathology results. METHODS: In this single-centre retrospective study, all patients diagnosed with ILC between 2014 and 2019 who underwent preoperative MRI were included. Specific parameters studied were: (1) the need for second-look targeted biopsies, (2) detection of new tumors (ie, contralateral or multifocal), (3) changes in cTNM-classification, and (4) impact on final treatment plan. Bland-Altman plots were used to compare the tumor sizes measured on MRI and FFDM/US with actual pathological tumor sizes. RESULTS: Ninety-nine patients were included. After performing preoperative MRI, 9 (9.1%) multifocal tumors were diagnosed after additional biopsies. Contralateral tumors were detected twice (2.0%) and cN classification was upgraded in 7 cases (7.1%). Surgical treatment or neoadjuvant treatment plans were changed in 16 patients (16.1%). Compared to histopathological results, FFDM/US underestimated tumor size with a mean of 0.4 cm (Limit of agreement (LoA): -2.8 cm to 2.0 cm) whereas MRI overestimated tumor size with a mean of 0.6 cm (LoA: -1.9 cm to 3.0 cm). CONCLUSIONS: In our study, mean differences in tumor size measurements using FFDM/US and MRI were comparable, with similar random errors. MRI correctly diagnosed multifocal and contralateral tumors more often and provided a better cN staging.

Seroma formation after mastectomy: A systematic review and network meta-analysis of different flap fixation techniques.

Flap fixation is the most promising solution to prevent seroma formation after mastectomy. In this systematic review with network meta-analysis (NMA), three different techniques were compared. The NMA included 25 articles, comprising 3423 patients, and revealed that sutures are superior to tissue glue in preventing clinically significant seroma. In addition, running sutures seemed to be superior to interrupted sutures. An RCT comparing these suture techniques seems necessary, given the quality and nature of existing literature.

Drain-free mastectomy and flap fixation: The interim analysis of a randomized controlled noninferiority trial.

INTRODUCTION: Flap fixation after mastectomy has proven to be one of the most promising solutions to reduce seroma formation. Drain placement remains standard practice in many clinics, even though this may be redundant after flap fixation. METHODS: This is a prospective randomized controlled trial comparing mastectomy and wound closure using flap fixation with or without drain placement. The primary outcome measure was clinically significant seroma (CSS) incidence. The aim of this interim analysis was to assess the assumptions for the sample size calculation and to provide preliminary results. RESULTS: Between July 2020 and January 2023, 112 patients were included. CSS incidence was 9.1% in the drain group and 21% in the no-drain group. In total, 10 patients were lost to follow-up. These numbers are similar to the ones used for the sample size calculation. In the drain group, three patients required interventions for wound complications compared to nine in the no-drain group (odds ratio: 3.612 [95% confidence interval: 0.898-14.537]). CONCLUSION: The sample size calculation seems to be correct and no protocol amendments are necessary. Current preliminary results show no significant differences in CSS incidence. Complete results should be awaited to draw a well-powered conclusion regarding drain policy after mastectomy.