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Issa TZ, Lin JS, Herrera F, Mailey B. Trends in the Surgical Management of Thoracic Outlet Syndrome. Hand (N Y) 2024; 19:367-373. [PMID: 36544244 PMCID: PMC11067839 DOI: 10.1177/15589447221141479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The operative treatment for thoracic outlet syndrome (TOS) varies in the United States. This may be due to differences in specialty training of the provider. We sought to identify which procedures are primarily performed by specialty, identify patient characteristics presenting for different neurogenic TOS surgical interventions, and describe the safety of TOS surgery. METHODS Patients treated for neurogenic TOS between 2016 and 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient characteristics, surgeon details, intraoperative variables, and complication outcomes were abstracted. Patient cohorts were stratified by type of operative intervention and by treating specialty. RESULTS Transthoracic first rib resection was the most common procedure performed for TOS relief (46.1%), followed by division of the scalene muscles with rib resection (23.9%) and brachial plexus exploration with decompression (19.4%). Vascular surgeons performed 87% of TOS repairs. Thirty-day complication rate was 3.5%. Addition of scalenectomy to first rib resection was common and resulted in increased operative time but did not increase early complication rate or readmission rate. CONCLUSION Patient characteristics and dispositions are similar between the various TOS operative approaches. All major surgical treatments for TOS have low complication rates. Transthoracic first rib resection performed by vascular surgeons remains the most common surgical treatment for patients with TOS in the United States. Despite neurogenic symptoms representing most cases, less than 10% of operations are performed by peripheral nerve specialists, highlighting a potential need for greater incorporation of TOS release into peripheral nerve practices.
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Sutton W, O'Neill J, Strother E, Grossman DA, Hwalek AE, Margolis M. Video-assisted thoracic surgery and robotic-assisted first-rib excision and thoracic outlet syndrome decompression. Semin Vasc Surg 2024; 37:82-89. [PMID: 38704188 DOI: 10.1053/j.semvascsurg.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 05/06/2024]
Abstract
Multiple surgical approaches have been used in the management of thoracic outlet syndrome. These approaches have traditionally been "open" approaches and have been associated with the inherent morbidities of an open approach, including a risk of injury to the neurovascular structures due to traction and trauma while resecting the first rib. In addition, there has been concern that recurrence of symptoms may be related to incomplete resection of the rib with conventional open techniques. With the advent of minimally invasive thoracic surgery, surgeons began to explore first-rib resection via a thoracoscopic approach. Unfortunately, the existing video-assisted thoracic surgery technology and equipment was not well suited to working in the apex of the chest. With the introduction and subsequent progress in robotic surgery and instrumentation, this dissection can be performed with all the advantages of robotics, but also with minimal traction and trauma to the neurovascular structures, and incorporates almost complete resection of the rib with minimal residual stump. Robotics has developed as a reliable, safe, and less invasive approach to first-rib resection, yielding excellent results while limiting the morbidity of the procedure.
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Affiliation(s)
- Whitney Sutton
- Department of Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC, 20007.
| | - John O'Neill
- Department of Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC, 20007
| | - Eric Strother
- Department of Cardiothoracic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Danielle A Grossman
- Department of Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC, 20007
| | - Ann E Hwalek
- Department of Cardiothoracic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Marc Margolis
- Department of Cardiothoracic Surgery, MedStar Georgetown University Hospital, Washington, DC
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Aimanan K, Ong MN, Koay KL, Siew CYE, Hayati F, Tajri H. Veno-Venous Surgical Bypass for Central Vein Occlusion in a Child: The First in the Literature. EJVES Vasc Forum 2023; 59:56-58. [PMID: 37396436 PMCID: PMC10310466 DOI: 10.1016/j.ejvsvf.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/11/2023] [Accepted: 05/15/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction During the past two decades, the incidence of chronic kidney disease (CKD) in children worldwide has steadily increased and, even in children, native arteriovenous fistula (AVF) remains the access of choice. Nevertheless, maintaining a well functioning fistula is limited by central venous occlusion due to the widespread use of central venous access devices before AVF creation. Report A 10 year old girl with end stage renal failure dialysing through a left brachiocephalic fistula presented with left upper limb and facial swelling. She had previously exhausted the option of ambulatory peritoneal dialysis for recurrent peritonitis. A central venogram showed occlusion at the left subclavian vein, which was not amenable for angioplasty through either an upper limb or femoral approach. Given the precious fistula with concomitant worsening venous hypertension, an ipsilateral axillary vein to external iliac vein bypass was performed. Subsequently, her venous hypertension was significantly resolved. This report is the first in English literature on this surgical bypass in a child with central venous occlusion. Discussion Central venous stenosis or occlusion rates are rising due to extensive central venous catheter use in the paediatric population with end stage renal failure. In this report, an ipsilateral axillary vein to external iliac vein bypass was used successfully as a safe temporary option to maintain AVF. Ensuring a high flow fistula pre-operatively and continued antiplatelet post-operatively will allow longer patency of the graft.
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Affiliation(s)
- Karthigesu Aimanan
- Department of Vascular Surgery, Hospital Serdang, Ministry of Health Malaysia, Kajang, Selangor, Malaysia
| | - Mang Ning Ong
- Department of Vascular Surgery, Hospital Serdang, Ministry of Health Malaysia, Kajang, Selangor, Malaysia
| | - Kean Leong Koay
- Department of Vascular Surgery, Hospital Serdang, Ministry of Health Malaysia, Kajang, Selangor, Malaysia
| | - Caroline Yin Eng Siew
- Department of Paediatrics, Hospital Tuanku Ja'afar Seremban, Ministry of Health Malaysia, Seremban, Negeri Sembilan, Malaysia
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Hafizan Tajri
- Department of Vascular Surgery, Hospital Serdang, Ministry of Health Malaysia, Kajang, Selangor, Malaysia
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Liu B, Gao S, Wu Q, Li H, Zhang G, Fu J. A case report of robotic-assisted resection of large fibrous benign tumor of second rib. J Cardiothorac Surg 2022; 17:329. [PMID: 36539826 PMCID: PMC9769036 DOI: 10.1186/s13019-022-02041-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surgical resection is the most effective curative management of benign rib tumors and carries an excellent prognosis. Due to complex anatomy and narrow field, higher rib resection is technically demanding and requires extensive dissection. CASE PRESENTATION We report a case of second rib tumor resection performed transthoracic under Da Vinci robot assistance. A 32-year-old male complained about increasing pain in the left anterior chest wall. After 3D reconstruction of CT, it showed a well-circumscribed fusiform lesion with a multi-component structure. Measured 17 × 6 × 4 cm and extended into the chest cavity to the depth below the pectoralis minor muscle. The patient underwent robotic-assisted trans-thoracic second rib resection. At four weeks of outpatient follow-up, the patient reported no pain and uncomplicated wound healing. CONCLUSION This minimally invasive approach offers optimal visualization and tissue manipulation while dramatically decreasing the possibility of collateral damage, hence ensuring fast function recovery. To the best of our knowledge, these kinds of procedures are rarely reported in detail.
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Affiliation(s)
- Bohao Liu
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Shan Gao
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Qifei Wu
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Haijun Li
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Guangjian Zhang
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Junke Fu
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
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Ahmed AS, Graf AR, Karzon AL, Graulich BL, Egger AC, Taub SM, Gottschalk MB, Bowers RL, Wagner ER. Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:469-488. [PMID: 37588453 PMCID: PMC10426640 DOI: 10.1016/j.xrrt.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.
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Affiliation(s)
- Adil S. Ahmed
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexander R. Graf
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Anthony L. Karzon
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Anthony C. Egger
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah M. Taub
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael B. Gottschalk
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert L. Bowers
- Department of Orthopaedic Surgery, Sports Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric R. Wagner
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
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F. Dengler N, T. Pedro M, Kretschmer T, Heinen C, Rosahl SK, Antoniadis G. Neurogenic Thoracic Outlet Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:735-742. [PMID: 35978467 PMCID: PMC9975980 DOI: 10.3238/arztebl.m2022.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/01/2022] [Accepted: 07/21/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) refers to a group of disorders in which there is compression of and/or damage to the neurovascular structures at the thoracic outlet, i.e., at the transition from chest to neck. The incidence of neurogenic thoracic outlet syndrome (nTOS) is estimated to be 2-3 / 100 000 / year, with an estimated prevalence of 10 / 100 000. Patients present with upper extremity sensorimotor symptoms that are often related to movement. The aim of the present article is to highlight the clinical presentation patterns of nTOS and to provide an overview of its diagnosis and treatment. METHODS Selective literature search for prospective observational studies and RCTs, including systematic reviews and metaanalyses. RESULTS There is no multicenter randomized controlled trial available on the treatment of nTOS. Prospective observational studies with a hierarchical study design report a positive effect of physiotherapy in 27-59% of cases. After unsuccessful conservative treatment, up to 56-90% benefit from surgical management. Patients with nTOS are more severely affected compared with those with other forms of TOS and benefit less from transaxillary first rib resection. nTOS patients who underwent supraclavicular decompression without rib resection had excellent surgical outcomes in 27%, good outcomes in 36%, acceptable outcomes in 26%, and poor surgical outcomes in 11% of cases. There is no systematic comparison available of the types of surgical management involved. Also, there is currently no uniform classification available for all medical sub-disciplines. Therefore, interpretation, and comparability of the study results are limited. CONCLUSION Although nTOS is the most common form of TOS, studies on its treatment are currently limited in terms of numbers and quality. The type of surgical management varies according to the experience and preference of the surgeon, treating specialty, special anatomic features, and clinical symptoms.
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Affiliation(s)
- Nora F. Dengler
- Department of Neurosurgery, Charité— Universitätsmedizin Berlin,*Charité – Universitätsmedizin Berlin Campus Benjamin Franklin Klinik für Neurochirurgie Hindenburgdamm 30, D-12203 Berlin, Germany
| | - Maria T. Pedro
- District Hospital of Günzburg, Neurosurgical Department of the University of Ulm
| | - Thomas Kretschmer
- Department of Neurosurgery and Neurorestauration, Klinikum Klagenfurt Am Wörthersee, Klagenfurt, Austria
| | - Christian Heinen
- Peripheral Nerve Unit Nord, Christliches Krankenhaus Quakenbrück GmbH, Quakenbrück
| | | | - Gregor Antoniadis
- District Hospital of Günzburg, Neurosurgical Department of the University of Ulm
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Satake H, Honma R, Nito T, Naganuma Y, Shibuya J, Maruyama M, Uno T, Takagi M. Midterm results of endoscopically assisted first rib resection in the zero position for thoracic outlet syndrome. Interact Cardiovasc Thorac Surg 2022; 35:6696242. [PMID: 36094365 PMCID: PMC9536291 DOI: 10.1093/icvts/ivac239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hiroshi Satake
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Ryusuke Honma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Toshiya Nito
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Yasushi Naganuma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Junichiro Shibuya
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Masahiro Maruyama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
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Lingyun W, Ke S, Jinmin Z, Yu Q, Jun Q. Derkash's Classification and Vas Visual Analog Scale to Access the Long-Term Outcome of Neurothoracic Outlet Syndrome: A Meta-Analysis and Systematic Review. Front Neurol 2022; 13:899120. [PMID: 35873776 PMCID: PMC9296859 DOI: 10.3389/fneur.2022.899120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Many publications report outcomes of surgical treatment for neurothoracic outlet syndrome (NTOS); however, high-quality meta-analyses regarding objective evaluation system accessing the long-term outcome of NTOS are lacking. This meta-analysis summarizes and compares the outcomes of Derkosh's classification and vas visual analog scale of the supraclavicular neuroplastic of brachial plexus (SNBP) and trams auxiliary first rib resection (TFRR). Methods The Cochrane Library, PubMed, EMBASE, Allied and Complementary Medicine (AMED) were searched for papers published between January 1980 and February 2021, using the keywords “thoracic outlet syndrome,” “treatment, surgical.” Articles were eligible for inclusion if the following criteria were met studies describing outcomes of surgery for NTOS, published in English, human studies, and available in full text. The exclusion criteria were case reports (n < 10), reviews, abstracts, and studies lacking a control group or without evaluation for two types of surgery. Results We included 10 studies with 1,255 cases, out of which 622 were in the SNBP group; and 633 were in the TFRR group. After surgery (≥12 months), Derkash's classification was improved in 425 cases with SNBP and 364 cases with TFRR. OR = 1.34 (95% CI: 0.94, 1.92), P = 0.03; vas visual analog scale was improved in 282 cases in the SNBP group and 214 cases in the TFRR group. OR = 1.08 (95% CI: 0.63, 1.85), P = 0.78. Conclusion This meta-analysis shows that both SNBP and TFRR are effective for NTOS, but that SNBP is better than TFRR in improving Derkash's classification in the long term. Although patients treated with SNBP are more satisfactory, there is no significant difference in vas visual analog scale from TFRR. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021254203, PROSPERO CRD42021254203.
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Affiliation(s)
- Wei Lingyun
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
- Department of Traumatic Hand Surgery, The First Affiliated Hospital of Guilin Medical College, Guilin, China
- *Correspondence: Wei Lingyun
| | - Sha Ke
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
| | - Zhao Jinmin
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
- Zhao Jinmin
| | - Qiao Yu
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
| | - Qin Jun
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
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Gkikas A, Lampridis S, Patrini D, Kestenholz PB, Azenha LF, Kocher GJ, Scarci M, Minervini F. Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review. Front Surg 2022; 9:848972. [PMID: 35350142 PMCID: PMC8957785 DOI: 10.3389/fsurg.2022.848972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThoracic outlet syndrome (TOS) is a pathological condition caused by a narrowing between the clavicle and first rib leading to a compression of the neurovascular bundle to the upper extremity. The incidence of TOS is probably nowadays underestimated because the diagnosis could be very challenging without a thorough clinical examination along with appropriate clinical testing. Beside traditional supra-, infraclavicular or transaxillary approaches, the robotic assisted first rib resection has been gaining importance in the last few years.MethodsWe conducted a retrospective cohort analysis of all patients who underwent robotic assisted first rib resection due to TOS at Lucerne Cantonal Hospital and then we performed a narrative review of the English literature using PubMed, Cochrane Database of Systematic Reviews and Scopus.ResultsBetween June 2020 and November 2021, eleven robotic assisted first rib resections were performed due to TOS at Lucerne Cantonal Hospital. Median length of stay was 2 days (Standard Deviation: +/– 0.67 days). Median surgery time was 180 min (Standard Deviation: +/– 36.5). No intra-operative complications were reported.ConclusionsRobotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.
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Affiliation(s)
- Andreas Gkikas
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
| | - Savvas Lampridis
- Department of Thoracic Surgery, 424 General Military Hospital, Thessaloniki, Greece
| | - Davide Patrini
- Department of Thoracic Surgery, University College London Hospitals, London, United Kingdom
| | - Peter B. Kestenholz
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Luis Filipe Azenha
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Gregor Jan Kocher
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Scarci
- Department of Thoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
- *Correspondence: Fabrizio Minervini
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10
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Completely thoracoscopic 3-port robotic first rib resection for thoracic outlet syndrome. Ann Thorac Surg 2021; 114:1238-1244. [PMID: 34592270 DOI: 10.1016/j.athoracsur.2021.08.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 08/03/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND In thoracic outlet syndrome (TOS), the constriction between bony and muscular structures leads to compression of the neurovascular bundle to the upper extremity. Traditional surgical techniques using supra-, infraclavicular or transaxillary approaches to remove the first rib do not usually allow good exposure of the entire rib and neurovascular bundle. We have therefore developed a robotic approach to overcome these limitations. METHODS Between January 2015 and November 2020, 38 consecutive first rib resections for neurogenic, venous or arterial TOS were performed in 34 patients at our institutions. For our completely portal approach, we used two 8mm working ports and one 12mm camera port. RESULTS The surgery time was between 71 to 270 min (median 133 min, SD+/-44.7 min) without any complications. Chest tube was removed on postoperative day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD+/-2.1 days). No relevant intra- or postoperative complications were observed and complete or subtotal resolution of symptoms was seen in all patients. CONCLUSIONS The robotic technique described here for first rib resection has proven to be a safe and effective approach. The unsurpassed exposure of the entire first rib and possibility for a robotic-assisted meticulous surgical dissection has prevented both intra- and postoperative complications. This makes this technique unique as the safest and most minimally invasive approach to date. It helps improving patient outcomes by reducing perioperative morbidity with an easily adoptable procedure.
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11
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Zehnder A, Lutz J, Dorn P, Minervini F, Kestenholz P, Gelpke H, Schmid RA, Kocher GJ. Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment? J Clin Med 2021; 10:3952. [PMID: 34501401 PMCID: PMC8432239 DOI: 10.3390/jcm10173952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71-270 min (median 128.5 min, SD +/- 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/- 2.1 days). Stent grafting was performed 5-35 days (mean 14.8 days, SD +/- 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.
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Affiliation(s)
- Adrian Zehnder
- Department of Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland; (A.Z.); (H.G.)
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Jon Lutz
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Patrick Dorn
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Kantonsspital Luzern, 6004 Lucerne, Switzerland; (F.M.); (P.K.)
| | - Peter Kestenholz
- Department of Thoracic Surgery, Kantonsspital Luzern, 6004 Lucerne, Switzerland; (F.M.); (P.K.)
| | - Hans Gelpke
- Department of Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland; (A.Z.); (H.G.)
| | - Ralph A. Schmid
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Gregor J. Kocher
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
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12
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Gelabert HA. Innovation and thoracic outlet surgery. J Vasc Surg 2021; 74:946. [PMID: 34425958 DOI: 10.1016/j.jvs.2021.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, Department of Surgery, UCLA Gonda Venous Center, UCLA Health, Los Angeles, Calif
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13
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Hoexum F, Jongkind V, Coveliers HM, Yeung KK, Wisselink W. Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome. Vascular 2021; 30:217-224. [PMID: 33832359 DOI: 10.1177/1708538121997332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars. METHODS We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire. RESULTS Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population. CONCLUSION Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.
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Affiliation(s)
- Frank Hoexum
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Vincent Jongkind
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | | | - Kak K Yeung
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Willem Wisselink
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
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14
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Abstract
Minimally invasive surgical approaches to the treatment of thoracic outlet syndrome (TOS) will become increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Robotic surgery may be more technically advantageous because of improved visualization and maneuverability of wristed instruments. Longer-term outcome data are necessary to definitively establish the equivalency or superiority of minimally invasive TOS compared with open surgery in the treatment of TOS.
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Affiliation(s)
- Christina L Costantino
- Department of Thoracic Surgery, Massachusetts General Hospital, Founders House, 265 Charles Street, FND-7, Boston, MA 02114, USA
| | - Lana Y Schumacher
- Department of Thoracic Surgery, Massachusetts General Hospital, Founders House, 265 Charles Street, FND-7, Boston, MA 02114, USA.
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15
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Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D, Paladini A, Varrassi G, Viswanath O, Urits I. Thoracic Outlet Syndrome: A Narrative Review. J Clin Med 2021; 10:jcm10050962. [PMID: 33804565 PMCID: PMC7957681 DOI: 10.3390/jcm10050962] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 01/08/2023] Open
Abstract
Thoracic outlet syndrome comprises a group of disorders that result in compression of the brachial plexus and subclavian vessels exiting the thoracic outlet. Symptoms include pain, paresthesia, pallor, and weakness depending upon the compromised structures. While consensus in diagnostic criteria has not yet been established, a thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis. General first-line therapy for thoracic outlet syndrome is a conservative treatment, and may include physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids. Patients who have failed conservative therapy are considered for surgical decompression. This article aims to review the epidemiology, etiology, relevant anatomy, clinical presentations, diagnosis, and management of thoracic outlet syndrome.
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Affiliation(s)
- Nathan Li
- Medical College of Wisconsin–Milwaukee, Milwaukee, WI 53233, USA;
| | - Gregor Dierks
- Louisiana State University Health Sciences Center–Shreveport, Shreveport, LA 71106, USA; (G.D.); (H.E.V.); (A.J.)
| | - Hayley E. Vervaeke
- Louisiana State University Health Sciences Center–Shreveport, Shreveport, LA 71106, USA; (G.D.); (H.E.V.); (A.J.)
| | - Allison Jumonville
- Louisiana State University Health Sciences Center–Shreveport, Shreveport, LA 71106, USA; (G.D.); (H.E.V.); (A.J.)
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA; (A.D.K.); (O.V.); (I.U.)
| | - Dariusz Myrcik
- Department of Internal Medicine, Medical University of Silesia, Katowice, 42-600 Bytom, Poland;
| | | | - Giustino Varrassi
- Paolo Procacci Foundation, Via Tacito 7, 00193 Roma, Italy
- Correspondence: ; Tel.: +39-348-606-8472
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA; (A.D.K.); (O.V.); (I.U.)
- Valley Anesthesiology and Pain Consultants–Envision Physician Services, Phoenix, AZ 85004, USA
- Department of Anesthesiology, University of Arizona, Phoenix, AZ 85004, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE 68114, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA; (A.D.K.); (O.V.); (I.U.)
- Southcoast Health, Southcoast Physicians Group Pain Medicine, Wareham, MA 02571, USA
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16
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Martinez BD, Albeshri H, Chulkov M, Alharthi S, Nazzal MMS, Sferra J. Development and evolution of a robotic surgical technique for the treatment of thoracic outlet syndrome. J Vasc Surg 2021; 74:938-945.e1. [PMID: 33639235 DOI: 10.1016/j.jvs.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We describe the development and evolution of a surgical technique that uses the robotic da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) for the transaxillary approach to repair the disabling thoracic outlet syndrome (TOS). We report our patient outcomes associated with the use of this robotic technique. METHODS We present a retrospective review and analysis of data collected from a 16-year experience of a single surgeon using a robotic surgical system and technique for TOS surgery. From the initial design of an endoscope attached to a microvideo camera in 1982 to the adoption of the monorobotic arm with integrated voice in 1998, the main objective of the transaxillary approach has always been to improve visualization of congenital cervical anomalies of the scalene muscles. From February 2003 to December 2018, we performed 412 transaxillary decompression procedures using the robotic da Vinci Surgical System. The surgical procedure has been described in further detail and includes the following steps: (1) positioning of the patient into a lateral decubitus position and using a monoarm retractor; (2) creation of a mini-incision in the axillary area and creation and maintenance of the subpectoral anatomic working space; (3) placement of endoscopic ports and engagement of the robotic instrumentation; (4) dissection of extrapleural and intrapleural soft tissue; (5) creation of the "floater" first rib; (6) excision of the cervical bands and first rib; and (7) placement of thoracostomy tubes for drainage and closure of the incisions. RESULTS None of the patients died, and no patient experienced permanent neurovascular damage of the extremity. Of the 306 patients, 22 (5% of 441 operations) experienced complications. One patient developed postoperative scarring that required a redo operation with a robotic-assisted transaxillary approach. CONCLUSIONS With its three-dimensional visual magnification of the anatomic area, the endoscopic robotic-assisted transaxillary approach offers safe and effective management of disabling TOS symptoms. The endoscope facilitates observation of the cervical bands and the mechanism (pathogenesis) of the neurovascular compression that causes TOS, thereby allowing complete excision of the first rib, cervical bands, and scalene muscle. We sought to develop and perfect this robotic approach. The present study was not intended to be a comparative study to nonrobotic TOS surgery.
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Affiliation(s)
- Bernardo D Martinez
- The University of Toledo College of Medicine and Life Sciences and ProMedica Toledo Hospital, Toledo, Ohio.
| | - Heitham Albeshri
- The University of Toledo College of Medicine and Life Sciences and ProMedica Toledo Hospital, Toledo, Ohio
| | - Maria Chulkov
- The University of Toledo College of Medicine and Life Sciences and ProMedica Toledo Hospital, Toledo, Ohio
| | - Samer Alharthi
- The University of Toledo College of Medicine and Life Sciences and ProMedica Toledo Hospital, Toledo, Ohio
| | - Munier M S Nazzal
- The University of Toledo College of Medicine and Life Sciences and ProMedica Toledo Hospital, Toledo, Ohio
| | - Joseph Sferra
- The University of Toledo College of Medicine and Life Sciences and ProMedica Toledo Hospital, Toledo, Ohio
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17
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Dorn P, Zehnder A, Kocher GJ. [Thoracic Outlet Syndrome: Rare, Often Missed or Over-Diagnosed?]. PRAXIS 2021; 110:391-396. [PMID: 34019442 DOI: 10.1024/1661-8157/a003660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Thoracic Outlet Syndrome: Rare, Often Missed or Over-Diagnosed? Abstract. The thoracic outlet syndrome (TOS) presents with various symptoms caused by compression of the neurovascular bundle in the region of the upper thoracic aperture. Since the pathogenesis also determines the therapy of TOS, the classification according to the affected structure into neurogenic, venous and arterial TOS (nTOS, vTOS and aTOS) is useful. However, mixed forms are often to be assumed, which are then usually also classified under the term 'non-specific or disputed TOS' in the group of nTOS. In the absence of a gold standard diagnostic test, accurate history taking and clinical examination continue to be of great importance. Diagnostic experience and therapeutic advances have led to hopeful possibilities in the challenging management of this condition.
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Affiliation(s)
- Patrick Dorn
- Klinik für Thoraxchirurgie, Inselspital, Universitätsspital Bern, Bern
| | - Adrian Zehnder
- Klinik für Thoraxchirurgie, Inselspital, Universitätsspital Bern, Bern
| | - Gregor J Kocher
- Klinik für Thoraxchirurgie, Inselspital, Universitätsspital Bern, Bern
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18
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Johansen K. Rib-sparing scalenectomy for neurogenic thoracic outlet syndrome: Early results. J Vasc Surg 2020; 73:2059-2063. [PMID: 33340695 DOI: 10.1016/j.jvs.2020.12.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Neurogenic thoracic outlet syndrome (NTOS) is no longer either "controversial" or "disputed"; however, its optimal surgical management remains unclear. Many thoracic outlet decompression procedures are performed by first rib resection, usually via a transaxillary route. METHODS A retrospective review of a prospectively maintained NTOS database was performed. Patients with NTOS associated with a cervical rib and those with recurrent NTOS were excluded from the present analysis. All study patients had satisfied a 5-point clinical diagnostic protocol and had experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis via a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All the patients had completed QuickDASH (11-item version of the Disability of the Arm, Shoulder, and Hand questionnaire) preoperatively and at 3 or 6 months postoperatively. RESULTS From 2011 to 2019, 504 thoracic outlet decompression procedures had been performed in 442 patients. The average operative time was 1.15 hours, and the average hospital length of stay was 1.05 days. Major complications, including intraoperative arterial injury, postoperative wound hematoma requiring reoperation, and chylothorax, occurred in 7 patients (1.4%). All but 2 patients (99.6%) had symptomatic improvement. Using a more rigorous definition of operative success of ≥50% improvement in the 3- or 6-month QuickDASH score, 458 rib-sparing NTOS operations (90.9%) were successful. In contrast to the mean preoperative QuickDASH score of 62.6, the average postoperative QuickDASH score was 25.2 (P = .001). CONCLUSIONS These results suggest that (1) adherence to a rigorous preoperative diagnostic regimen, including performance of a scalene block, ensures, at the least, that surgery for NTOS can be successfully restricted to patients actually with the condition; (2) fibrotic, contracted scalene muscles are the cause of NTOS; (3) the first rib does not require removal for successful surgical treatment of NTOS; and (4) 90% of the patients so treated can expect significant early symptomatic and functional improvement.
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Affiliation(s)
- Kaj Johansen
- Department of Surgery, Swedish Medical Center, Seattle, Wash.
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19
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Commentary: Robotic first rib resection: A safe, modern update. J Thorac Cardiovasc Surg 2020; 162:1306-1307. [PMID: 33218753 DOI: 10.1016/j.jtcvs.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/20/2022]
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20
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Shi J, Hsin M. Commentary: Do Robots Do it Better? Semin Thorac Cardiovasc Surg 2020; 32:1121-1122. [PMID: 32569646 DOI: 10.1053/j.semtcvs.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jianxin Shi
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Michael Hsin
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong.
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21
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Fairman AS, Fairman RM, Foley PJ, Etkin Y, Jackson OA, Jackson BM. Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome? Ann Vasc Surg 2020; 69:217-223. [PMID: 32497616 DOI: 10.1016/j.avsg.2020.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/26/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. METHODS Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. RESULTS Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. CONCLUSIONS This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.
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Affiliation(s)
- Alexander S Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Ronald M Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul J Foley
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Benjamin M Jackson
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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22
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Pupovac SS, Lee PC, Zeltsman D, Jurado J, Hyman K, Singh V. Robotic-Assisted First Rib Resection: Our Experience and Review of the Literature. Semin Thorac Cardiovasc Surg 2020; 32:1115-1120. [PMID: 32446920 DOI: 10.1053/j.semtcvs.2020.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/20/2020] [Indexed: 11/11/2022]
Abstract
Thoracic outlet syndrome (TOS) comprises a constellation of signs and symptoms that arise from neurologic and vascular compression of the brachial plexus and subclavian vasculature, respectively. Surgical decompression of the neurovascular structures is often indicated to alleviate TOS. We report here our robotic surgical approach and experience for resection of the first rib. Between July 2014 and January 2017, 17 patients who underwent robotic-assisted first rib resection at our institution were reviewed. Nine women and 8 men with a mean age of 45 ± 11 years had a robotic-assisted first rib resection; 8 for neurogenic TOS and 9 for venous TOS. There were no complications or conversion to open surgery. The mean operative time was 113.2 ± 55.3 minutes. Length of stay was a mean of 1.8 ± 1.9 days. Length of rib resected was 5.8 ± 0.5 cm. Anticoagulation for the venous TOS cohort was Xarelto, for a mean of 5.1 ± 1.8 months. Short-term follow-up (mean 10.3 ± 4.9 days) revealed resolution of symptoms in all patients, with patent vasculature on venogram for the entire venous TOS cohort. Further follow-up at 2 months and 6 months revealed that all patients remained symptom free. Based on our institution's experience with the robotic-assisted approach to first rib resection, we feel that it is a feasible approach that could be added to the armamentarium of the thoracic surgeon.
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Affiliation(s)
- Stevan S Pupovac
- Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Queens, New York.
| | - Paul C Lee
- Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Queens, New York
| | - David Zeltsman
- Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Queens, New York
| | - Julissa Jurado
- Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Queens, New York
| | - Kevin Hyman
- Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Queens, New York
| | - Vijay Singh
- Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Queens, New York
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