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Talutis SD, Ulloa JG, Gelabert HA. The impact of competitive level of high school and collegiate athletes on outcomes of thoracic outlet syndrome. J Vasc Surg 2024; 79:388-396. [PMID: 37931887 DOI: 10.1016/j.jvs.2023.10.061] [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: 08/25/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Thoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes. METHODS This was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P < .05. RESULTS Thirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P = .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P = .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P = 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P = .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P = .15). Operating room time was 90.0 vs 105.3 minutes for HS and CO athletes, respectively (P = .14). Mean length of stay was 2.0 vs 1.9 days for HS and CO athletes (P = .91). Mean follow-up was 6.9 months for HS athletes and 10.5 months for CO athletes (P = .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P = 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P = .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P = .035). CONCLUSIONS Despite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes.
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Affiliation(s)
- Stephanie D Talutis
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA.
| | - Jesus G Ulloa
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
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Wang K, Talutis SD, Ulloa JG, Gelabert HA. Erector Spinae versus Surgically Placed Pain Catheters for Thoracic Outlet Decompression. Ann Vasc Surg 2024; 98:268-273. [PMID: 37806656 DOI: 10.1016/j.avsg.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/08/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Perioperative care after surgery for thoracic outlet syndrome (TOS) involves multimodal pain control. Pain catheters with bupivacaine infusion are a modality to minimize perioperative narcotic use. Our study aims to compare surgically placed pain catheters (SP) with erector spinae pain catheters (ESP) placed by the anesthesia pain service. METHODS Retrospective review of a prospectively maintained surgical TOS database identified patients undergoing transaxillary first rib resection (FRR) who had either SP or ESP placed for pain control. Patients were matched for age and gender. Data collected included demographics, operative details, and perioperative pain medication use. Narcotic pain medication doses were converted to milligram morphine equivalents (MMEs) for comparison between groups. Pain medications were collected for several time points: intraoperatively, for each postoperative day (POD) and for the entire hospital stay. RESULTS Eighty-eight total patients were selected for comparison: 44 patients in the SP and ESP groups. Patients in each group did not differ with regards to age, body mass index, gender, diagnosis, or comorbidities. There were no differences in preoperative narcotic use, preoperative pain score, or Quick Disabilities of Arm, Shoulder, and Hand score. All patients underwent FRR. Concurrent cervical rib resection was performed in 6.8% SP and 6.8% ESP patients (P = 1.00), pectoralis minor tenotomy in 34.1% SP and 29.5% ESP patients (P = 0.65), and venogram in 31.8% SP and 31.8% ESP patients (P = 1.00). Mean operating room time was 90.0 min in SP and 105.3 min in ESP cases (P = 0.15). Mean length of stay was 1.9 days for SP and 1.8 days for ESP patients (P = 0.56). There were no significant differences in intraoperative narcotics dosing in MME (SP: 22.1 versus ESP: 25.3, P = 0.018). On POD 0, there were no differences in total narcotics dosing (MME) (SP: 112.0 versus ESP: 100.7, P = 0.59), or in the use of acetaminophen, nonsteroidal anti-inflammatory drugs, or muscle relaxants. A similar trend in narcotics dosing was observed on POD 1 (SP: 58.6 versus ESP: 69.7, P = 0.43) and POD 2 (SP: 23.5 versus ESP: 71.3, P = 0.23). On POD 1, there was a higher percentage of SP patients taking nonsteroidal anti-inflammatory drugs (63.6% vs. 40.9%, P = 0.024); however, this difference was not observed on POD 2. There were no differences in acetaminophen or muscle relaxant use on POD 1 or 2. Total hospital stay MME was similar between groups (SP: 215.9 versus ESP: 250.9, P = 0.23). CONCLUSIONS Pain catheters with bupivacaine infusions are helpful adjuncts in postoperative pain control after FRR for TOS. This study compares SP to ESP and demonstrates no difference in narcotics use between SP and ESP groups. SP should be used for pain control in facilities which do not have an anesthesia pain service available for ESP placement.
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Affiliation(s)
- Karissa Wang
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
| | - Stephanie D Talutis
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA.
| | - Jesus G Ulloa
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
| | - Hugh A Gelabert
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
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Talutis SD, Ulloa JG, Gelabert HA. Adolescent athletes can get back in the game after surgery for thoracic outlet syndrome. J Vasc Surg 2023; 77:599-605. [PMID: 36243264 DOI: 10.1016/j.jvs.2022.10.002] [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: 06/28/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We compared the functional outcomes among adolescent athletes with venous thoracic outlet syndrome (VTOS) and neurogenic TOS (NTOS) after thoracic outlet decompression. METHODS We performed a single-institution retrospective review of a prospective database of adolescent athletes (aged 13-19 years) from June 1, 1996 to December 31, 2021 who had undergone operative decompression for TOS. The demographic data, preoperative symptoms, operative details, and postoperative outcomes were compared. The primary outcome was the postoperative return to sport. The secondary outcomes included symptom resolution and assessment of the somatic pain scale, QuickDASH, and Derkash scores. The Fisher exact test and t test were used to evaluate the categorical and continuous variables, respectively. A logistic regression model was constructed to adjust for the influence of preoperative factors and return to sport. RESULTS A total of 60 patients (40.0% with VTOS and 60.0% with NTOS) were included. The average age of the VTOS patients was 17.2 years vs 16.6 years for the NTOS patients (P = .265). The NTOS patients were more likely to be female (88.9% vs 62.5%; P = .024). The NTOS patients had more frequently presented with pain (97.2% vs 70.8%; P = .005), paresthesia (94.4% vs 29.1%; P = .021), and weakness (67.7% vs 12.5%; P = .004) but had less often reported swelling (25.0% vs 95.8%; P < .001). At presentation, the NTOS patients had also reported a longer symptom duration (17.7 months vs 3.1 months; P < .001). Transaxillary first rib resection with subtotal scalenectomy was performed for 100% of the VTOS patients and 94.4% of the NTOS patients undergoing cervical rib resection (2.8%) or scalenectomy alone (2.8%). Additionally, 11.1% of the NTOS patients had undergone combined first rib resection and cervical rib resection. For the VTOS patients, postoperative venography showed patent subclavian veins in 27.8%. In addition, 44.4% had required venoplasty, 16.8% had required thrombolysis, and 11% were chronically occluded. No significant differences were found in blood loss, operative time, or length of stay between the groups. No surgical complications occurred. The average follow-up was 6.3 months. Significant differences were found between the VTOS and NTOS groups for the pre- and postoperative somatic pain scale, QuickDASH, and Derkash scores. Complete symptom resolution had occurred in 83.3% of the VTOS and 75% of the NTOS patients (P = .074). No statistically significant difference in the return to sport was observed between the two groups (VTOS, 94.4%; vs NTOS, 73.9%; P = .123). Of the NTOS patients, 10.0% had had other concomitant injuries and 5.0% had had medical conditions that had precluded their return to sport. Logistic regression found no significant relationship between the preoperative somatic pain scale score, QuickDASH score, or duration of symptoms and the return to sport. CONCLUSIONS Adolescent athletes with VTOS and NTOS can have good functional outcomes, and most will be able to return to sport after surgery. Greater initial symptom severity and concomitant injuries were observed in adolescents with NTOS. Of those who had not returned to sport postoperatively, three of seven had had unrelated health issues that had prevented their return to sport.
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Affiliation(s)
- Stephanie D Talutis
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California, Los Angeles, Los Angeles, CA.
| | - Jesus G Ulloa
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California, Los Angeles, Los Angeles, CA
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California, Los Angeles, Los Angeles, CA
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Talutis SD, Gelabert HA, O'Connell J, Ulloa JG. When healing hands hurt: Epidemiology of thoracic outlet syndrome among physicians. Ann Vasc Surg 2022; 88:18-24. [PMID: 36162629 DOI: 10.1016/j.avsg.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thoracic outlet syndrome is an infrequent condition which results in disability in use of upper extremity. While is often associated with manual labor, industrial workers, and accidents, it has not been reported in a physician population. Given the investment of time and effort in training to become a physician, the impact of TOS may be devastating. Our objective is to report the presentation and outcome of TOS in physicians. METHODS A prospectively surgical database was reviewed for physicians who sought care of disabling TOS between 1997 and 2022. Demographic, clinical, outcome and pathological data were reviewed. Outcomes were assessed based on Somatic Pain Scale (SPS), Quick DASH scores, and Derkash scores. Results were also assessed based on return to employment. RESULTS A total of 19 MDs were identified, from 1687 TOS cases. The group included 13 (63%) men, 6 (31%) women, average age 45 year (range 27-57). Presentations included 1 (5.3%) Arterial TOS (ATOS), 9 (47.4%) Venous TOS (VTOS), and 9 (47.4) Neurogenic TOS (NTOS). All patients were right-handed, and symptomatic side was dominant hand in 7 (37%). Etiologies included repetitive motion injury, athletic injury, and congenital bony abnormalities. Repetitive motion was associated with 3/9 (33%) NTOS. Significant athletic activities were noted in 12 of 19 (63%), including 8/9 (89%) VTOS and 4/9 (44%) NTOS. Athletic activities associated with VTOS included triathletes (2), rock climbing (1), long distance swimming (2), weightlifting (3). Of the 9 NTOS cases, 3 weightlifting, 1 skiing. Congenital causes included 1 (5%) abnormal first rib, and 1 (5%) cervical rib. Time from symptom onset to consultation varied significantly according to diagnosis: ATOS 6 days, VTOS 97 days, NTOS 2,335 days (p<0.05). All underwent first rib resection (FRR), and four (4) required contralateral FRR. Time from surgery to last follow up averaged 1,005 days (range: 37 to 4535 days). On presentation, 6 were work disabled, 13 were work restricted. Following surgery 4 remained work restricted with mild to moderate symptoms. After surgery, standardized outcomes (SPS, Quick DASH, Derkash score) improved in all metrics. All who were initially disabled returned to work without restriction. Significant non-TOS related co-morbidities were present in all who had residual restriction. Return to work was documented in all. CONCLUSIONS Although it has not been reported, physicians are subject to developing TOS. Causes include repetitive motions, athletic injuries, and congenital bony abnormalities. Surgical decompression is beneficial with significant reduction in pain and disability. Physicians are highly motivated and insightful; accordingly, they have a very high probability of successful work resumption, with all returning to their medical positions.
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Affiliation(s)
- Stephanie D Talutis
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA.
| | - Hugh A Gelabert
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Jessica O'Connell
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Jesus G Ulloa
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA, USA
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Ammi M, Hersant J, Henni S, Daligault M, Papon X, Abraham P, Picquet J. Evaluation Of Quality Of Life After Surgical Treatment Of Thoracic Outlet Syndrome. Ann Vasc Surg 2022; 85:276-283. [PMID: 35339598 DOI: 10.1016/j.avsg.2022.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND To evaluate the quality of life of surgically treated patients for TOS. METHODS A prospective observational study including patients treated surgically for TOS, on 2018. Two standardized questionnaires: Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Short-Form 12 (SF-12) were used. The SF-12 consists of a physical and mental component (PCS-SF-12 and MCS-SF-12). The questionnaires were completed during the preoperative and postoperative consultations and at 3, 6, and 12 months. RESULTS We performed 53 interventions. The population was mostly female (n = 35, 66.0%) of 40.1±10.0 years. The preoperative DASH score was 46.3±19.7. It was 40.9±21.7 at 6 weeks, 33.5±22.7 at 3 months, 28.9±22.6 at 6 months, and 21.1±20 at 9 to 12 months. The improvement of DASH becomes statistically significant at 3 months (p = 0.036), 6 months (p = 0.002), and 12 months (p = 0.001). The preoperative MCS-SF-12 was 36.6±9.4. It was 41.6±10.9 at 6 weeks, 43.8±11.1 at 3 months, 46.2±11.8 at 6 months, and 51.4±8 at 8 to 12 months. The improvement of MCS-SF-12 became significant at 3 months (p=0.009), 6 months (p=0.001), and 12 months (p=0.001). The preoperative PCS-SF-12 was 35.5±6.4. It was 37.1±8.7 at 6 weeks, 39.9±8.7 at 3 months, 41.6±8.4 at 6 months, and 46.1±8.1 to 12 months. The improvement of PCS-SF-12 became significant at 6 months (p=0.005) and 12 months (p=0.001). CONCLUSION The surgical management of TOS allows an improvement of quality of life in short and medium term.
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Affiliation(s)
- Myriam Ammi
- Department of Vascular and Thoracic Surgery, University Hospital, 49933 Angers, France.
| | - Jeanne Hersant
- Department of Vascular and Sport Investigations, University Hospital, 49933 Angers, France
| | - Samir Henni
- Department of Vascular and Thoracic Surgery, University Hospital, 49933 Angers, France
| | - Mickael Daligault
- Department of Vascular and Thoracic Surgery, University Hospital, 49933 Angers, France
| | - Xavier Papon
- Department of Vascular and Thoracic Surgery, University Hospital, 49933 Angers, France
| | - Pierre Abraham
- Department of Vascular and Sport Investigations, University Hospital, 49933 Angers, France
| | - Jean Picquet
- Department of Vascular and Thoracic Surgery, University Hospital, 49933 Angers, France
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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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Nuutinen H, Kärkkäinen JM, Kimmo M, Voitto A, Teemu R, Petri S, Janne P. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6545787. [PMID: 35262705 PMCID: PMC9252101 DOI: 10.1093/icvts/ivac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Henrik Nuutinen
- Department of Surgery, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
- Corresponding author. Henrik Nuutinen, Kuopio University Hospital, Department of Surgery. PL 100, 70029 Kuopio, Finland. e-mail:
| | | | - Mäkinen Kimmo
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Aittola Voitto
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Saari Petri
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Pesonen Janne
- Department of Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland
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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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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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Milagres VAMV, Avellar RLDS, Silva APP, Pires PJ, Pinto DM. Treatment of upper limb arterial occlusion caused by a cervical rib. J Vasc Bras 2021; 20:e20200193. [PMID: 34211537 PMCID: PMC8218826 DOI: 10.1590/1677-5449.200193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The cervical rib syndrome occurs when the interscalene triangle is occupied by a cervical rib, displacing the brachial plexus and the subclavian artery forward, which can cause pain and muscle spasms. The objective of this study is to discuss diagnosis of the cervical rib syndrome and treatment possibilities. This therapeutic challenge describes clinical and surgical management of a 37-year-old female patient with upper limb arterial occlusion caused by a cervical rib.
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Furushima K, Funakoshi T, Kusano H, Miyamoto A, Takahashi T, Horiuchi Y, Itoh Y. Endoscopic-Assisted Transaxillary Approach for First Rib Resection in Thoracic Outlet Syndrome. Arthrosc Sports Med Rehabil 2021; 3:e155-e162. [PMID: 33615259 PMCID: PMC7879182 DOI: 10.1016/j.asmr.2020.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 08/31/2020] [Indexed: 11/03/2022] Open
Abstract
Purpose To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach. Methods We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores. Results We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score. Conclusions An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure. Level of Evidence IV, therapeutic case series.
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Moridzadeh RS, Gelabert MC, Rigberg DA, Gelabert HA. A novel technique for transaxillary resection of fully formed cervical ribs with long-term clinical outcomes. J Vasc Surg 2020; 73:572-580. [PMID: 32707395 DOI: 10.1016/j.jvs.2020.07.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Although the supraclavicular approach has been widely adopted for cervical rib resection, a transaxillary approach has been favored by many. We have reviewed more than two decades of experience with decompression of the thoracic outlet to treat thoracic outlet syndrome (TOS) in patients with complete cervical ribs using a novel transaxillary approach. METHODS A prospectively maintained database of patients undergoing surgery for TOS was searched for patients with complete (class 3 and 4) cervical ribs from 1997 to 2019. All these patients had undergone transaxillary resection using a technique in which the cervical and first ribs were separated and then individually resected. The data abstracted included patient demographics, symptoms, surgical details, and complications. The outcomes were contemporaneously assessed clinically and using standardized functional tools: somatic pain scale (SPS) and Quick Disabilities of the Arm, Hand, and Shoulder questionnaire (QuickDASH). The cervical rib data were organized and reported in accordance with the Society for Vascular Surgery reporting standards. RESULTS During the study period, 1506 patients had undergone surgery for TOS at our institution. Of these 1506 patients, 38 had undergone complete transaxillary resection of 40 fully formed cervical ribs (10 class 3 and 30 class 4). Of these 38 patients, 74% were women. The presentations had been neurogenic (65%), arterial (31%), and venous (5%). The average initial SPS and QuickDASH score was 6.4 and 50, respectively. The duration of surgery averaged 141 minutes, blood loss was 65 mL, and length of stay was 2.1 days. None of the patients had experienced brachial plexus, phrenic, or long thoracic nerve injury. The average follow-up period was 65 months. The final mean postoperative SPS and QuickDASH scores were lower than the scores at presentation (SPS score, 6.4 vs 1.2; P < .001; QuickDASH score, 50 vs 17; P < .001). CONCLUSIONS To the best of our knowledge, the present study is the largest reported experience of resection of fully formed cervical ribs using a transaxillary approach that allowed for individual dissection and removal of cervical and first rib segments. This technique has proved to be successful, with low morbidity and reliable improvement in patient symptom and disability scores. Based on these reported outcomes, this novel approach to transaxillary resection of fully formed cervical ribs should be considered a safe and effective operation.
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Affiliation(s)
- Rameen S Moridzadeh
- Division of Vascular and Endovascular Surgery, UCLA Gonda Vascular Center, University of California, Los Angeles, Los Angeles, Calif
| | - Maria C Gelabert
- Division of Vascular and Endovascular Surgery, UCLA Gonda Vascular Center, University of California, Los Angeles, Los Angeles, Calif
| | - David A Rigberg
- Division of Vascular and Endovascular Surgery, UCLA Gonda Vascular Center, University of California, Los Angeles, Los Angeles, Calif
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, UCLA Gonda Vascular Center, University of California, Los Angeles, Los Angeles, Calif.
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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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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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Stilo F, Montelione N, Benedetto F, Spinelli D, Vigliotti RC, Spinelli F. Thirty-year experience of transaxillary resection of first rib for thoracic outlet syndrome. INT ANGIOL 2019; 39:82-88. [PMID: 31814380 DOI: 10.23736/s0392-9590.19.04300-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years. METHODS A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates. RESULTS One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%). CONCLUSIONS In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.
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Affiliation(s)
- Francesco Stilo
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | - Nunzio Montelione
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy -
| | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical, Dental Sciences and Morphofunctional Imaging, G. Martino Policlinic Hospital, University of Messina, Messina, Italy
| | - Domenico Spinelli
- Unit of Vascular Surgery, Department of Biomedical, Dental Sciences and Morphofunctional Imaging, G. Martino Policlinic Hospital, University of Messina, Messina, Italy
| | - Rossella C Vigliotti
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy.,Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Francesco Spinelli
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
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Kocher GJ, Zehnder A, Lutz JA, Schmidli J, Schmid RA. First Rib Resection for Thoracic Outlet Syndrome: The Robotic Approach. World J Surg 2018; 42:3250-3255. [PMID: 29696329 DOI: 10.1007/s00268-018-4636-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE First rib resection is a well-recognized treatment option for thoracic outlet syndrome (TOS). In case of a vascular insufficiency that can be provoked and/or progressive neurologic symptoms without response to conservative treatment, surgical decompression of the space between the clavicle and the first rib is indicated. The aim of this paper is to present our experience with a new minimally invasive robotic approach using the da Vinci Surgical System®. METHODS Between January 2015 and October 2017, eight consecutive first rib resections in seven patients were performed at our institution. Four patients presented with neurologic (one bilateral), and three patients with vascular (venous) impairment. In all cases, a transthoracic robotic-assisted approach was used. The first rib was removed using a 3-port robotic approach with an additional 2-cm axillary incision in the first six patients. The latest resection was performed through only three thoracic ports. RESULTS Median operative time was 108 min, and the median hospital stay was 2 days. Postoperative courses were uneventful in all patients. Clinical follow-up examinations showed relief of symptoms in all nonspecific TOS patients, and duplex ultrasonography confirmed complete vein patency in the remaining patients 3 months after surgery. CONCLUSIONS While there are limitations in conventional transaxillary, subclavicular and supraclavicular approaches in the first rib resection, the robotic method is not only less invasive but also allows better exposure and visualization of the first rib. Furthermore, the technique takes advantage of the benefits of the da Vinci Surgical System® in terms of 3D visualization and improved instrument maneuverability. Our early experience clearly demonstrates these advantages, which are also supported by the very good outcomes.
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Affiliation(s)
- Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Adrian Zehnder
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jon A Lutz
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Juerg Schmidli
- Division of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ralph A Schmid
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
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Gelabert HA, Rigberg DA, O'Connell JB, Jabori S, Jimenez JC, Farley S. Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs. J Vasc Surg 2018; 68:1143-1149. [DOI: 10.1016/j.jvs.2018.01.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/30/2018] [Indexed: 11/30/2022]
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Archie MM, Rollo JC, Gelabert HA. Surgical Missteps in the Management of Venous Thoracic Outlet Syndrome Which Lead to Reoperation. Ann Vasc Surg 2018; 49:261-267. [DOI: 10.1016/j.avsg.2018.01.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 11/20/2017] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
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Aghayev K, Ciklatekerlio O. Posterior Upper Rib Excision for Neurogenic Thoracic Outlet Syndrome---Feasibility and Early Outcomes. Oper Neurosurg (Hagerstown) 2018; 14:532-537. [PMID: 29106657 DOI: 10.1093/ons/opx143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 06/06/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are several surgical treatment options for neurogenic thoracic outlet syndrome (n-TOS). However, the first rib has been shown to be the common denominator of all TOS forms and the degree of its resection has been shown to correlate with the long-term success. OBJECTIVE To demonstrate the feasibility of posterior upper rib excision (PURE) and report early outcomes. METHODS Nine patients presented with signs and symptoms of n-TOS. Preoperative evaluation involved physical and neurological examination, arm visual analog score (VAS), cervical X-ray, magnetic resonance imaging (MRI) of the cervical spine, and brachial plexus MRI. All patients were operated at a single institution by a single surgeon. Postoperatively, clinical and radiological data were collected. RESULTS There were 2 men and 7 women in the study with 10 procedures performed. The age range was 18 to 45 with mean of 36.6 yr. Mean preoperative arm visual analog scale score was 7.8. The patients underwent posterior upper rib excision (PURE) by a single surgeon. One patient had bilateral surgery. The causes of TOS were fibrous bands, enlarged C7 transverse processes, narrow scalene triangle, and accessory ribs. All patients improved after surgery in terms of arm pain and quality of life. Postoperative mean visual analog scale score was 1.1 at 6 mo. In addition, neurological examination was normal at 6 mo postoperatively and all patients returned to their previous full-time jobs. CONCLUSION Posterior upper rib excision is a feasible surgical option for n-TOS.
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Affiliation(s)
- Kamran Aghayev
- Department of Neurosurgery, Biruni Uni-versity, Istanbul, Turkey
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Nuutinen H, Riekkinen T, Aittola V, Mäkinen K, Kärkkäinen JM. Thoracoscopic Versus Transaxillary Approach to First Rib Resection in Thoracic Outlet Syndrome. Ann Thorac Surg 2018; 105:937-942. [DOI: 10.1016/j.athoracsur.2017.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/14/2017] [Accepted: 10/02/2017] [Indexed: 11/16/2022]
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Vos CG, Ünlü Ç, de Vries JPP. Commentary on 'Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome'. J Thorac Dis 2017; 8:3046-3048. [PMID: 28066579 DOI: 10.21037/jtd.2016.11.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Cornelis G Vos
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Çağdaş Ünlü
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
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George RS, Milton R, Chaudhuri N, Kefaloyannis E, Papagiannopoulos K. Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome. Ann Thorac Surg 2016; 103:241-245. [PMID: 27659601 DOI: 10.1016/j.athoracsur.2016.06.075] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/13/2016] [Accepted: 06/20/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) causes neurologic symptoms in 95% of cases and vascular symptoms in 5% of cases. Surgical resection is curative. Endoscopic-assisted transaxillary first rib resection has been previously reported. In this study we report a totally endoscopic video-assisted thoracoscopic surgery (VATS) approach using tailored endoscopic instruments. METHODS Ten patients (8 women; average age, 32.3 ± 5.6 years) with TOS underwent VATS first rib resection following failure of symptom improvement with physiotherapy. Symptoms were: unilateral neurogenic (n = = 7), bilateral neurogenic (n = = 2), and bilateral arterial compression (n = = 1). Three standard VATS ports were utilized. The parietal pleura and periosteum overlying the first rib were stripped avoiding injury to the neurovascular bundle. The rib was transected with an endoscopic rib cutter and resected completely in a piecemeal fashion using endoscopic bone nibblers. All periosteal remnants were trimmed releasing the neurovascular bundle completely. RESULTS Patients were discharged within 72 hours following surgery. One patient had the contralateral side treated 18 months later and another patient is awaiting the second surgery. At follow-up, 9 patients had complete resolution of their main symptoms. One patient with neurogenic TOS developed mild functional and sensational loss of the non-dominant hand that improved within 8 months with physiotherapy. CONCLUSIONS VATS first rib resection for TOS provides, unlike the classic approaches, a superior, magnified, and well-illuminated view of the thoracic inlet. It allows good posterior trimming of the first rib, release of brachial plexus, and an aesthetically pleasing result, especially in female patients.
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Affiliation(s)
- Robert S George
- Department of Thoracic Surgery, St. James's University Hospital, Leeds Teaching Hospitals, United Kingdom
| | - Richard Milton
- Department of Thoracic Surgery, St. James's University Hospital, Leeds Teaching Hospitals, United Kingdom
| | - Nilanjan Chaudhuri
- Department of Thoracic Surgery, St. James's University Hospital, Leeds Teaching Hospitals, United Kingdom
| | - Emmanuel Kefaloyannis
- Department of Thoracic Surgery, St. James's University Hospital, Leeds Teaching Hospitals, United Kingdom
| | - Kostas Papagiannopoulos
- Department of Thoracic Surgery, St. James's University Hospital, Leeds Teaching Hospitals, United Kingdom.
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Kara HV, Balderson SS, Tong BC, D'Amico TA. Video assisted transaxillary first rib resection in treatment of thoracic outlet syndrome (TOS). Ann Cardiothorac Surg 2016; 5:67-9. [PMID: 26904437 DOI: 10.3978/j.issn.2225-319x.2015.08.09] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- H Volkan Kara
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Stafford S Balderson
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Betty C Tong
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Thomas A D'Amico
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
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Gelabert HA, Jabori S, Barleben A, Kiang S, O'Connell J, Jimenez JC, DeRubertis B, Rigberg D. Regrown First Rib in Patients with Recurrent Thoracic Outlet Syndrome. Ann Vasc Surg 2014; 28:933-8. [DOI: 10.1016/j.avsg.2014.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 01/15/2014] [Accepted: 01/15/2014] [Indexed: 11/30/2022]
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