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Barron JO, Jain N, Mubashir M, Elgharably H, Raymond DP, Schraufnagel DP. Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report. J Chest Surg 2024; 57:213-216. [PMID: 38221730 DOI: 10.5090/jcs.23.099] [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: 08/02/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 01/16/2024] Open
Abstract
Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.
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Affiliation(s)
- John O Barron
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Nethra Jain
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mujtaba Mubashir
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dean P Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Mamoun N, Rosser MA, Manning M, Raghunathan K, McCartney S, Mehta S, Ingle K, Bottiger B. Pain trajectories after bilateral orthotopic lung transplantation surgery performed via a clamshell incision. Clin Transplant 2024; 38:e15262. [PMID: 38369849 DOI: 10.1111/ctr.15262] [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: 11/15/2023] [Revised: 01/10/2024] [Accepted: 01/29/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using pain trajectories for the study cohort, in addition to stratifying patients into separate pain trajectory groups and investigating their association with donor and recipient perioperative variables. METHODS After obtaining IRB approval, we retrospectively included all patients ≥18 years old who underwent primary BOLT via clamshell incision at a single center between January 1, 2017, and June 30, 2022. We modeled the overall pain trajectory using pain scores collected over the first seven postoperative days and identified separate pain trajectory classes via latent class analysis. RESULTS Three hundred one adult patients were included in the final analysis. Three separate pain trajectory groups were identified, with most patients (72.8%) belonging to a well-controlled, stable pain trajectory. Uncontrolled pain was either observed in the early postoperative period (10%), or in the late postoperative period (17.3%). Late postoperative peaking trajectory patients were younger (p = .008), and sicker with a higher lung allocation score (p = .005), receiving preoperative mechanical ventilation (p < .001), or VV-ECMO support (p < .001). CONCLUSION Despite the extensive nature of a clamshell incision, most pain trajectories in BOLT patients had a well-controlled stable pain profile. The benign nature of pain profiles in our patient population may be attributed to the routine institutional practice of early thoracic epidural analgesia for BOLT patients unless contraindicated.
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Affiliation(s)
- Negmeldeen Mamoun
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Morgan A Rosser
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Manning
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sharon McCartney
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sachin Mehta
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Krista Ingle
- Department of Psychiatry and Behavioral Science, Duke University Medical Center, Durham, North Carolina, USA
| | - Brandi Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Fernández AM, Ruiz E, Cantador B, González FJ, Baamonde C, Álvarez A. Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation. Transplant Proc 2023; 55:2307-2308. [PMID: 37798166 DOI: 10.1016/j.transproceed.2023.08.031] [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: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. CASE REPORT A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. CONCLUSION Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.
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Affiliation(s)
- Alba María Fernández
- Thoracic Surgery and Lung Transplantation Department, Reina Sofía University Hospital, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Spain
| | - Eloísa Ruiz
- Thoracic Surgery and Lung Transplantation Department, Reina Sofía University Hospital, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Spain
| | - Benito Cantador
- Thoracic Surgery and Lung Transplantation Department, Reina Sofía University Hospital, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Spain
| | - Francisco Javier González
- Thoracic Surgery and Lung Transplantation Department, Reina Sofía University Hospital, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Spain
| | - Carlos Baamonde
- Thoracic Surgery and Lung Transplantation Department, Reina Sofía University Hospital, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Spain
| | - Antonio Álvarez
- Thoracic Surgery and Lung Transplantation Department, Reina Sofía University Hospital, Córdoba, Spain; Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Spain.
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Al-Abassi A, Papini M, Towler M. Review of Biomechanical Studies and Finite Element Modeling of Sternal Closure Using Bio-Active Adhesives. Bioengineering (Basel) 2022; 9:198. [PMID: 35621476 PMCID: PMC9138150 DOI: 10.3390/bioengineering9050198] [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] [Received: 04/18/2022] [Accepted: 04/23/2022] [Indexed: 11/17/2022] Open
Abstract
The most common complication of median sternotomy surgery is sternum re-separation after sternal fixation, which leads to high rates of morbidity and mortality. The adhered sternal fixation technique comprises the wiring fixation technique and the use of bio-adhesives. Adhered sternal fixation techniques have not been extensively studied using finite element analysis, so mechanical testing studies and finite element analysis of sternal fixation will be presented in this review to find the optimum techniques for simulating sternal fixation with adhesives. The optimal wiring technique should enhance bone stability and limit sternal displacement. Bio-adhesives have been proposed to support sternal fixation, as wiring is prone to failure in cases of post-operative problems. The aim of this paper is to review and present the existing numerical and biomechanical sternal fixation studies by reviewing common sternal closure techniques, adhesives for sternal closure, biomechanical modeling of sternal fixation, and finite element modeling of sternal fixation systems. Investigating the physical behavior of 3D sternal fixation models by finite element analysis (FEA) will lower the expense of conducting clinical trials. This indicates that FEA studies of sternal fixation with adhesives are needed to analyze the efficiency of this sternal closure technique virtually.
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Affiliation(s)
- Amatulraheem Al-Abassi
- Department of Biomedical Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada; (M.P.); (M.T.)
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
| | - Marcello Papini
- Department of Biomedical Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada; (M.P.); (M.T.)
- Department of Mechanical Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada
| | - Mark Towler
- Department of Biomedical Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada; (M.P.); (M.T.)
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
- Department of Mechanical Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada
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Boudreaux JC, Urban M, Berkheim DB, Moulton MJ, Small BL, Strah HM, Siddique A. Combination plate and band fixation for primary closure in bilateral lung transplantation. J Card Surg 2021; 36:3085-3091. [PMID: 34133049 DOI: 10.1111/jocs.15729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sternal complications are common following transverse thoracosternotomy in patients undergoing bilateral lung transplantation. We present a single-institution experience using a next generation rigid fixation system for primary sternal closure following transverse sternotomy for bilateral lung transplantation. METHODS Retrospective review was performed on all patients who had bilateral sequential lung transplants utilizing a transverse thoracosternotomy from 2016 to 2020. Demographics, baseline characteristics, peri-operative data, and outcomes were collected, reviewed and summarized. Two groups of patients were identified: wire cerclage (Group A), combination plate-and-band rigid fixation (Group B). The primary outcome was sternal complications, which were divided into mechanical and non-mechanical. RESULTS Twenty-two patients met inclusion criteria. Three patients (13.6%) were in Group A, nineteen patients (86.4%) in Group B. Two patients in each Group A (66.6%) and Group B (10.5%) experienced a sternal complication. Sternal complications included sternal dehiscence (2), sternal malunion (1), and surgical site infection (1). One patient with plate-and-band fixation (5.2%) had a mechanical sternal complication. Three patients required reoperation secondary to sternal complication. CONCLUSIONS The utilization of a combination plate-and-band rigid fixation system for primary closure is safe and may be an effective method to reduce sternal complications following transverse thoracosternotomy for lung transplantation.
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Affiliation(s)
- Joel C Boudreaux
- University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA
| | - Marian Urban
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David B Berkheim
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael J Moulton
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bronwyn L Small
- Department of Internal Medicine, Pulmonary Critical Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Heather M Strah
- Department of Internal Medicine, Pulmonary Critical Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Aleem Siddique
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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A mass sacrifice of children and camelids at the Huanchaquito-Las Llamas site, Moche Valley, Peru. PLoS One 2019; 14:e0211691. [PMID: 30840642 PMCID: PMC6402755 DOI: 10.1371/journal.pone.0211691] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 01/18/2019] [Indexed: 01/30/2023] Open
Abstract
Here we report the results of excavation and interdisciplinary study of the largest child and camelid sacrifice known from the New World. Stratigraphy, associated artifacts, and radiocarbon dating indicate that it was a single mass killing of more than 140 children and over 200 camelids directed by the Chimú state, c. AD 1450. Preliminary DNA analysis indicates that both boys and girls were chosen for sacrifice. Variability in forms of cranial modification (head shaping) and stable isotope analysis of carbon and nitrogen suggest that the children were a heterogeneous sample drawn from multiple regions and ethnic groups throughout the Chimú state. The Huanchaquito-Las Llamas mass sacrifice opens a new window on a previously unknown sacrificial ritual from fifteenth century northern coastal Peru. While the motivation for such a massive sacrifice is a subject for further research, there is archaeological evidence that it was associated with a climatic event (heavy rainfall and flooding) that could have impacted the economic, political and ideological stability of one of the most powerful states in the New World during the fifteenth century A.D.
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Panchabhai TS, Chaddha U, McCurry KR, Bremner RM, Mehta AC. Historical perspectives of lung transplantation: connecting the dots. J Thorac Dis 2018; 10:4516-4531. [PMID: 30174905 DOI: 10.21037/jtd.2018.07.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lung transplantation is now a treatment option for many patients with end-stage lung disease. Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung transplantation, to recognize major milestones in the field, and to learn from others' unsuccessful transplant experiences. James Hardy was instrumental in developing experimental thoracic transplantation, performing the first human lung transplant in 1963. George Magovern and Adolph Yates carried out the second human lung transplant a few days later. With a combined survival of only 26 days for these first 2 lung transplant recipients, the specialty of lung transplantation clearly had a long way to go. The first "successful" lung transplant, in which the recipient survived for 10.5 months, was reported by Fritz Derom in 1971. Ten years later, Bruce Reitz and colleagues performed the first successful en bloc transplantation of the heart and one lung with a single distal tracheal anastomosis. In 1988, Alexander Patterson performed the first successful double lung transplant. The modern technique of sequential double lung transplantation and anastomosis performed at the mainstem bronchus level was originally described by Henri Metras in 1950, but was not reintroduced into the field until Pasque reported it again in 1990. Since then, lung transplantation has seen landmark changes: evolving immunosuppression regimens, clarifying the definition of primary graft dysfunction (PGD), establishing the lung allocation score (LAS), introducing extracorporeal membrane oxygenation (ECMO) as a bridge to transplant, allowing donation after cardiac death, and implementing ex vivo perfusion, to name a few. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps summarize what has been achieved, and identifies opportunities for future generations of transplant pulmonologists and surgeons alike.
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Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Udit Chaddha
- Department of Pulmonary and Critical Care Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Sydell and Arnold Miller Family Heart and Vascular Institute
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Atul C Mehta
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Costa J, Sonett JR, D’Ovidio F. Modified Transverse Thoracosternotomy and Cost-Effective Reinforced Sternal Closure. Ann Thorac Surg 2015; 100:2376-8. [DOI: 10.1016/j.athoracsur.2015.05.122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 11/26/2022]
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9
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Koster TD, Ramjankhan FZ, van de Graaf EA, Luijk B, van Kessel DA, Meijer RC, Kwakkel-van Erp JM. Crossed wiring closure technique for bilateral transverse thoracosternotomy is associated with less sternal dehiscence after bilateral sequential lung transplantation. J Thorac Cardiovasc Surg 2013; 146:901-5. [DOI: 10.1016/j.jtcvs.2013.04.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 04/04/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
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Motomura T, Bruckner B, La Francesca S, Mittelhaus S, Chike-Obi C, Leon-Becerril J, Ngo U, Loebe M. Experience of Sternal Secondary Closure by Means of a Titanium Fixation System After Transverse Thoracosternotomy. Artif Organs 2011; 35:E168-73. [DOI: 10.1111/j.1525-1594.2011.01295.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sternum Sparing Thoracotomy Incisions in Lung Transplantation Surgery a Superior Technique to the Clamshell Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011; 6:116-21. [DOI: 10.1097/imi.0b013e3182166163] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Bilateral anterior transsternal thoracotomy incision (clamshell technique) is the standard approach used for bilateral sequential lung transplantation (LTX). The morbidity and wound complications of this large incision can be considerable and costly. Muscle sparing anterior thoracotomies without division of the sternum may lead to decreasing the sequelae of wound complications. The objective of this study was to determine the rate of wound complications in the nonsternal incising lung transplant patients. Methods We used the single-institution-based transplant data bank, phone questionnaire, and ambulatory care unit follow-up data to investigate retrospectively the incidence of wound healing complications following muscle and sternum sparing and mammary artery protecting limited access small submammary anterior thoracotomy incisions (AT) for LTX surgery. In the need for cardiopulmonary bypass, the femoral artery and vein were cannulated. Results After exclusion of seven clamshell operations for LTX combined with cardiac surgery, 91 recipients (65% male), aged 19 to 68 years (mean, 54 ± 8 years), underwent 84 AT and 48 lateral thoracotomies (LT) for idiopathic pulmonary fibrosis (IPF) (48%), obstructive disease (40%), cystic fibrosis (CF) (5%), and pulmonary arterial hypertension (PAH) (7%). AT ranged from 5.5 to 26 cm (mean, 20.3 ± 4.8 cm) and LT from 12 to 25 cm (mean, 19.8 ± 2.4 cm) and was not significantly different (P = 0.37). Warm ischemic times ranged from 30 to 92 minutes (mean, 56 ± 11 minutes). Four patients required rethoracotomy for bleeding/hematoma formation. Cardiopulmonary bypass/intraop extracorporeal membrane oxygenation (ECMO) was used in 64%. Superficial wound infection and subsequent drainage/care was needed in four LTX incisions. Reoperation for lung herniation using patch repair technique for thoracic wall stabilization was required in two AT and three LT. Conclusions Sternum sparing and mammary artery protecting limited access submammary anterior and lateral thoracotomy incisions for LTX surgery are safe and effective. This approach avoids complications related to sternal transaction and may minimize the development of severe wound complications following LTX surgery.
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Bittner HB, Lehmann S, Binner C, Garbade J, Barten M, Mohr FW. Sternum Sparing Thoracotomy Incisions in Lung Transplantation Surgery a Superior Technique to the Clamshell Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hartmuth Bruno Bittner
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Sven Lehmann
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Christian Binner
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Jens Garbade
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Markus Barten
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
| | - Friedrich Wilhelm Mohr
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany
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Venuta F, Rendina EA, Klepetko W, Rocco G. Surgical management of stage III thymic tumors. Thorac Surg Clin 2011; 21:85-91, vii. [PMID: 21070989 DOI: 10.1016/j.thorsurg.2010.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thymic tumors are classified as stage III when they clearly invade the surrounding structures: pericardium, great vessels (superior vena cava, innominate veins, ascending aorta, and main pulmonary artery), lung parenchyma, phrenic nerves, and chest wall. Surgical treatment with or without induction therapy should always aim to complete resection removing en bloc all the involved structures. Also, extended procedures are justified because only R0 resection allows long-term survival.
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Affiliation(s)
- Federico Venuta
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome Sapienza, Cattedra di Chirurgia Toracica, Viale del Policlinico, 00166 Rome, Italy.
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D'Andrilli A, Venuta F, Rendina EA. Surgical Approaches for Invasive Tumors of the Anterior Mediastinum. Thorac Surg Clin 2010; 20:265-84. [DOI: 10.1016/j.thorsurg.2010.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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15
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Gandy KL, Moulton MJ. Sternal Plating to Prevent Malunion of Transverse Sternotomy in Lung Transplantation. Ann Thorac Surg 2008; 86:1384-5. [DOI: 10.1016/j.athoracsur.2008.03.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 03/12/2008] [Accepted: 03/20/2008] [Indexed: 11/29/2022]
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Sternal wound dehiscence after transverse thoracosternotomy for bilateral lung transplantation: Report of a case. Surg Today 2008; 38:942-4. [DOI: 10.1007/s00595-007-3735-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 11/04/2007] [Indexed: 10/21/2022]
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Oto T, Venkatachalam R, Morsi YS, Marasco S, Pick A, Rabinov M, Rosenfeldt F. A reinforced sternal wiring technique for transverse thoracosternotomy closure in bilateral lung transplantation: From biomechanical test to clinical application. J Thorac Cardiovasc Surg 2007; 134:218-24. [PMID: 17599512 DOI: 10.1016/j.jtcvs.2007.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 02/22/2007] [Accepted: 03/08/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES A high incidence of failure of transverse thoracosternotomy closure, involving the loops of wire cutting through the sternum, remains a significant morbidity after bilateral lung transplantation. We postulated that placing peristernal wires inside the usual longitudinal wires could prevent the longitudinal wires from cutting through the sternum. The aims of this study were to investigate the biomechanical and clinical efficacy of the proposed reinforced sternal closure technique. METHODS In vitro, 24 artificial sternal models were wired with the reinforced or conventional wiring techniques and were tested either by means of longitudinal distraction or anterior-posterior shear (n = 6 per group). In vivo, the 6-month outcomes of 70 bilateral lung transplantations, including 27 reinforced and 43 conventional wiring techniques, were assessed. RESULTS Reinforced wiring was stronger than conventional wiring for both longitudinal distraction (yield load: 585 +/- 60 vs 334 +/- 21 N [P = .03]; maximum load: 807 +/- 60 vs 525 +/- 34 N [P = .03]; postyield stiffness: 91.0 +/- 22.0 vs 32.8 +/- 11.8 N/mm [P = .04]) and anterior-posterior shear (yield load: 405 +/- 9 vs 364 +/- 16 N [P = .03]; postyield stiffness: 47.4 +/- 6.1 vs 27.5 +/- 5.1 N/mm [P = .04]). In multivariate analysis, the use of the conventional wiring technique (odds ratio, 5.38; P = .04) and osteoporosis (odds ratio, 18.31; P = .0005) were significant risk factors associated with sternal dehiscence. In the patients with osteoporosis (n = 25), the incidence of sternal dehiscence in the reinforced wiring group (4/16 [25%]) was significantly lower than that in the conventional wiring group (7/9 [78%], P = .02). CONCLUSION Osteoporosis is a significant risk factor for sternal dehiscence after bilateral lung transplantation. The new reinforced sternal wiring technique provides biomechanically superior fixation of the sternum and clinically reduces the incidence of sternal dehiscence in high-risk osteoporotic patients undergoing bilateral lung transplantation.
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Affiliation(s)
- Takahiro Oto
- Department of Cardiothoracic Surgery, Heart and Lung Transplant Unit, The Alfred Hospital, Monash University, Melbourne, Australia.
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Turkoz R, Gulcan O, Demirturk OS, Turkoz A. Cannulation of the Ascending Aorta in Left Thoracotomy for Thoracic Aortic Aneurysms. Heart Surg Forum 2007; 10:E81-3. [PMID: 17311771 DOI: 10.1532/hsf98.20041167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In patients with aneurysms of the thoracic aorta, the risks of cerebral embolism and malperfusion are increased if retrograde aortic perfusion via the femoral artery is used during repair. We describe a surgical technique used for 6 aneurysms of the thoracic descending aorta that were operated on via thoracotomy with cannulation of the ascending aorta and deep hypothermic circulatory arrest.
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Affiliation(s)
- Riza Turkoz
- Department of Cardiovascular Surgery, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey.
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Dürrleman N, Massard G. Clamshell and hemiclamshell incisions. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2006.001867. [PMID: 24412942 DOI: 10.1510/mmcts.2006.001867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Sternotomy is one of the most frequent accesses in cardio-thoracic surgery. Transverse sternotomy with bilateral thoracotomy and combined approaches are developed. Surgical techniques, indications and pitfalls of these incisions are described.
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Affiliation(s)
- Nicolas Dürrleman
- Hôpitaux Universitaires de Strasbourg, Département de Chirurgie Thoracique, Hôpital Civil, 1 Place de l'Hôpital, 67000 Strasbourg, France
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Affiliation(s)
- Kalpaj Parekh
- Washington University School of Medicine, Department of Cardiothoracic Surgery, St. Louis, MO 63110, USA
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McGiffin DC, Alonso JE, Zorn GL, Kirklin JK, Young KR, Wille KM, Leon K, Hart K. Sternal Approximation For Bilateral Anterolateral Transsternal Thoracotomy For Lung Transplantation. Ann Thorac Surg 2005; 79:e19-20. [PMID: 15680800 DOI: 10.1016/j.athoracsur.2004.09.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2004] [Indexed: 11/18/2022]
Abstract
The traditional incision for bilateral sequential lung transplantation is the bilateral anterolateral transsternal thoracotomy with approximation of the sternal fragments with interrupted stainless steel wire loops; this technique may be associated with an unacceptable incidence of postoperative sternal disruption causing chronic pain and deformity. Approximation of the sternal ends was achieved with peristernal cables that passed behind the sternum two intercostal spaces above and below the sternal division, which were then passed through metal sleeves in front of the sternum, the cables tensioned, and the sleeves then crimped. Forty-seven patients underwent sternal closure with this method, and satisfactory bone union occurred in all patients. Six patients underwent removal of the peristernal cables: 1 for infection (with satisfactory bone union after the removal of the cables), 3 for cosmetic reasons, 1 during the performance of a median sternotomy for an aortic valve replacement, and 1 in a patient who requested removal before commencing participation in football. This technique of peristernal cable approximation of sternal ends has successfully eliminated the problem of sternal disruption associated with this incision and is a useful alternative for preventing this complication after bilateral lung transplantation.
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Affiliation(s)
- David C McGiffin
- Division of Cardiovascular and Thoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama 35294-0007, USA.
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Abstract
The technical aspects of lung transplantation have been refined over the past two decades. Anomalous donor anatomy and suboptimal harvests do not preclude transplantation, but they must be appropriately dealt with to ensure good outcomes. New techniques have been developed to increase the donor pool. Techniques for recipient pneumonectomy and graft implantation have been optimized, and ways of dealing with difficult exposures and anatomic variants have been designed. Novel methods for prevention of ischemia-reperfusion injury have been developed based on experimental studies, but more complete clinical scrutiny is needed to determine their impact.
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Affiliation(s)
- Christine L Lau
- Division of Cardiothoracic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Queeny Tower, Suite 3108, Box #8234, St. Louis, MO 63110, USA
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Lee J, Yew WW, Chiu CSW, Wong PC, Wong CF, Wang EP. Delayed sternotomy wound infection due to Paecilomyces variotii in a lung transplant recipient. J Heart Lung Transplant 2002; 21:1131-4. [PMID: 12398880 DOI: 10.1016/s1053-2498(02)00404-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report a case of sternotomy wound infection caused by Paecilomyces variotii in a previously bronchiectatic patient, occurring 10 months after bilateral sequential lung transplantation. The use of prophylactic antifungal therapy, the persistent colonization with Paecilomyces, and sternal instability after clamshell incision may have contributed to the development of delayed deep sternal wound infection. Besides antifungal therapy, vigorous surgical debridement is vital for treatment success. With the more liberal use of early post-transplant fungal prophylaxis, potentially drug-resistant fungi, such as the Paecilomyces species, may be emerging as important opportunistic pathogens after lung transplantation.
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Affiliation(s)
- Joseph Lee
- Tuberculosis and Chest Unit, Grantham Hospital, Aberdeen, Hong Kong, China.
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Harada T, Nakayama K, Kitano T, Sakaguchi H. Transsternal bilateral thoracotomy for pericardiectomy after coronary artery bypass grafting. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2000; 48:480-3. [PMID: 10965626 DOI: 10.1007/bf03218181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Surgery for constrictive pericarditis was conducted through a transsternal bilateral thoracotomy in a 45-year-old man who developed the condition 12 months after coronary artery bypass grafting with left internal thoracic artery and vein grafts. The grafts ran just beneath the sternum. To avoid injury to the bypass grafts during sternotomy and mediastinal dissection, we conducted a transsternal bilateral thoracotomy, which provided excellent exposure of the heart. Complete pericardiectomy was done safely without cardiopulmonary bypass. Constrictive pericarditis following cardiac surgery is an uncommon complication posing difficult problems for the surgeon. The presence of a patent left internal thoracic artery bypass is particularly challenging. Transsternal bilateral thoracotomy is a useful approach in patients with constrictive pericarditis in whom a median sternotomy is contraindicated.
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Affiliation(s)
- T Harada
- Department of Cardiovascular Surgery, Shimane Prefectural Central Hospital, Japan
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Varela A, Montero CG, Castedo E, Roda J, Gámez P, Madrigal L, Ugarte J. Transcutaneous extracorporeal cannulation for bilateral lung transplantation without splitting the sternum. J Thorac Cardiovasc Surg 2000; 119:402-3. [PMID: 10649223 DOI: 10.1016/s0022-5223(00)70203-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P. Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg 1999; 15:333-9. [PMID: 10333032 DOI: 10.1016/s1010-7940(99)00009-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the influence of either incision on the lungs and chest wall. METHODS Ninety-two double lung (DLT) or heart-lung (HLT) transplantations were done since January 1990. There were 22 (24%) hospital deaths, leaving 70 patients with complete data for evaluation. We did 38 DLT and 32 HLT for end-stage chronic respiratory failure (n = 22) and primary (n = 34) or secondary (n = 14) pulmonary hypertension, using 37 fourth or fifth interspace clamshell incisions and 33 median sternotomies. RESULTS The clamshell group included a higher percentage of DLTs (73 vs. 33%, P = 0.001) but recipient age, gender, preoperative diagnosis, bronchial anastomotic complications, number of cytomegalovirus infection, episode of acute rejection per patient-months and incidence of bronchiolitis obliterans were not statistically different between the two groups. At a follow-up time of 3.7 +/- 2 years, the overall 5-year survival of 57% was not influenced by the type of incision. The clamshell incision caused sternal over-riding in 12 (32%) patients, and eight surgical clamshell revision were necessary as compared with one median sternotomy (P = 0.02). The clamshell incision was associated with a significantly higher incidence of postoperative chronic pain (27 vs. 6%, P = 0.02). Postoperative mechanical properties of the chest wall were significantly (P < 0.0001) worse in the clamshell-group patients while the intrinsic properties of the airways were not different. CONCLUSIONS The clamshell incision results in more postoperative deformity, chronic pain, and impaired function as compared with median sternotomy. A bilateral anterolateral thoracotomy without division of the sternum is proposed for the sequential bilateral lung transplantation technique.
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Affiliation(s)
- P Macchiarini
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue (Paris-Sud University), Le Plessis Robinson, France.
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Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasc Surg 1999; 117:358-64. [PMID: 9918978 DOI: 10.1016/s0022-5223(99)70434-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to assess the efficacy and safety of an alternative surgical incision for bilateral sequential lung transplantation. The vast majority of these operations worldwide have been performed through an anterolateral thoracosternotomy known as the "clamshell" incision. Recently, we have undertaken most of these operations through bilateral anterolateral thoracotomies without sternal division. METHODS Our medical center performed 262 bilateral sequential single lung transplantations from 1989 to April 1998. Between July 1996 and April 1998 we performed 69 bilateral sequential single lung transplantations on 68 recipients with 52 transplantations being conducted without initial sternal division. We retrospectively reviewed the results of these operations to assess the safety of the altered exposure and the efficacy in avoiding sternal wound complications such as malunion, dehiscence, osteomyelitis, and migrating hardware. Comparison was made to a historical control group composed of the last 50 patients in whom the full clamshell incision was used. RESULTS Of the 68 patients who underwent transplantations, 52 patients underwent the initial exploratory procedure without sternal division. Two patients required emergency sternal division for institution of cardiopulmonary bypass to control life-threatening bleeding. Eleven of 68 patients were placed on bypass electively to permit transplantation, and the lack of a sternotomy in 8 patients did not present an obstacle to ascending aortic and right atrial cannulation. There were no wound healing complications in the 50 patients for whom the sternum was left intact. In a historical control group of 50 patients who underwent transplantation with sternal division, 34% experienced morbidity or mild disability as a direct result of poor sternal healing. CONCLUSIONS We conclude that bilateral anterolateral thoracotomy without sternal division is a safe approach that allows adequate exposure without the risk of commonly observed problems with sternal healing.
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Affiliation(s)
- B F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo., USA
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