Sparing internal thoracic vessels in thoracoscopic or submuscular correction of pectus carinatum: a porcine model study

Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jpedsurg.2015.07.023.Background: External compression is used for pectus carinatum (PC) treatment, but many patients are noncompliant. Costal cartilage resection (CCR) has been described as an alternative, but these approaches sacrifice the internal thoracic arteries (ITA). We aim to assess the feasibility of CCR sparing ITA comparing thoracoscopic and subcutaneous endoscopic approaches. Methods: Twelve pigs were used as models for surgical PC correction and randomized for 2 groups: thoracoscopy (T) and subcutaneous (subpectoralis) endoscopy (SP). In both groups, CCR from 3rd 4th and 5th ribs was performed avoiding ITA damage. ITA preservation was confirmed by Doppler-ultrasound as well as postmortem injection of methylene blue. Four persons evaluated the procedures being difficult, using a 6-item modified validated scale. Results: In both techniques, the procedure was accomplished in all animals sparing ITAs. CCR was faster in T than in SP (49 +/- 5 vs. 65 +/- 16 minutes, p < 0.05). T was classified as easier than SP (p < 0.001) with a significantly higher score for all items, especially better image and tissue handling. Discussion: Sparing the ITAs during CCR for correction of PC is feasible in a porcine model and might be a goal in humans. The thoracoscopic approach allows for a faster and easier procedure.info:eu-repo/semantics/publishedVersio

Duhamel pull-through assisted by transrectal port: a hybrid natural orifice transluminal endoscopic surgery approach

One of the latest surgical innovations is natural orifice transluminal endoscopic surgery (NOTES). We hypothesize that the principles of NOTES could be applied to the laparoscopic Duhamel procedure. Between March 2008 and May 2010, 3 children underwent the laparoscopic Duhamel procedure assisted by transrectal NOTES. Three 5-mm transabdominal trocars were combined with a 12-mm transrectal trocar. We were able to safely apply the principles of NOTES, improving the performance of laparoscopic Duhamel pull-through using current instruments and technology. This new approach avoids the need of an extra transabdominal 12-mm trocar for the endoscopic stapler, allows an easier creation of a smaller rectal stump, and offers the possibility of an extra working port. This hybrid concept can be seen as a transition into the emerging field of NOTES in colorectal surgery

Pulmonary myofibroblastic tumour involving the pericardium and left atrium in an 18 month infant

Inflammatory myofibroblastic tumor (IMT) is the most frequent primary lung tumor in children and it may be locally aggressive. The management of a locally advanced pulmonary IMT in an 18 month-old female child is presented. A left pulmonary mass was incidentally found on the computerized tomography (CT) scan of a child with persistent systemic inflammatory syndrome. Biopsy confirmed the diagnosis; after preoperative corticotherapy,left pneumonectomy was performed. The pericardium and left atrium were invaded and resected,requiring pericardial reconstruction. There is no relapse at four years of follow-up. Steroids play a role in tumor size reduction,but marginal resection is the gold standard. Extended approaches are feasible and often required in advanced cases.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Intraoperative acidosis and hypercapnia during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia/tracheoesophageal fistula

BACKGROUND: Intraoperative hypercapnia and acidosis have been associated with thoracoscopic repair of both congenital diaphragmatic hernia and esophageal atresia/tracheoesophageal fistula. AIM: The aim of the present study was to investigate whether thoracoscopic repair of congenital diaphragmatic hernia or esophageal atresia/tracheoesophageal fistula was associated with acidosis and hypercapnia in a large group of neonates, and to analyze the effects of acidosis and hypercapnia on early postoperative outcomes. METHODS: We reviewed the charts of neonates who underwent open or thoracoscopic congenital diaphragmatic hernia or esophageal atresia/tracheoesophageal fistula repair (2004-2014). Patients with available intraoperative arterial gas values were included. Data (PaCO2: mm Hg) were compared using paired/unpaired tests and are reported as difference [95% confidence interval]. RESULTS: Congenital diaphragmatic hernia: 187 neonates underwent open (n=153) or thoracoscopic (n=34) repair. Intraoperative arterial gas values were recorded in 96 open and in 23 thoracoscopic operations. Both groups had similar preoperative pH and PaCO2, and developed intraoperative acidosis (open −0.08 [−0.11, −0.05] P<.001, thoracoscopic −0.14 [−0.24, −0.04] P=.01) and hypercapnia (open: 7.8 [3.2, 12.4], P=.002; thoracoscopic: 20.2 [−2.5, 43, P=.07). Intraoperatively, neonates undergoing thoracoscopic repair developed lower pH than those having open surgery (−0.06 [−0.01, −0.10] P=.018), but maintained similar levels of PaCO2 (−4.0 [−9.0, 4.4] P=.39). Esophageal atresia/tracheoesophageal fistula: 205 neonates underwent open (n=180) or thoracoscopic (n=25) repair. Intraoperative arterial gas values were recorded in 62 open and in 14 thoracoscopic operations. Both groups had similar preoperative pH and PaCO2, and developed intraoperative acidosis (open: −0.09 [−0.14, −0.04], P<.001; thoracoscopic: 0.21 [−0.28, −0.14], P<.001) and hypercapnia (open: 9.2 [2.6, 15.7] P=.008; thoracoscopic: 15.2 [1.6, 28.7], P=.03). Intraoperatively, neonates undergoing thoracoscopic repair developed lower pH than those having open surgery (difference 0.08 [0.01, 0.15], P=.02) but maintained similar levels of PaCO2 (difference −1 [−9, 3], P=.35). CONCLUSION: Neonates undergoing operative repair of congenital diaphragmatic hernia and esophageal atresia/tracheoesophageal fistula develop intraoperative acidosis and hypercapnia, regardless of the approach used. However, this phenomenon is more severe during thoracoscopic repair. Novel modalities to reduce intraoperative gas derangements, particularly during thoracoscopic repair, need to be established

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used