Challenges and Opportunities in Thoracic Surgery

Special Issue:

Challenges and Opportunities in Thoracic Surgery

Opanasenko Mykola, MD
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Tereshkovych Oleksandr, MD
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Kalenychenko Maksym, PhD, Researcher
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Shalahai Serhii, Senior Researcher
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Konik Bohdan, PhD
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Levanda Larysa, Anesthetist
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Lysenko Volodymyr, Junior Researcher
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Stepaniuk Aliona, thoracic surgeon
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Shamrai Maksym, Anesthetist
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Bilokon Serhii, Junior Researcher
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Shestakova Oleksandra, Anesthetist
State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky National Academy of Sciences of Ukraine “, Department of Thoracic Surgery and Invasive Diagnostic Methods.

Abstract

Introduction. Multi/extensive drug-resistant lung tuberculosis (MDR/EDR–TB) is a serious problem as in Ukraine as throughout the world. The number of patients with pulmonary MDR/EDR–TB is increasing year by year, which is due to the difficulties in early detection of this disease.

The aim. To analyze the results of pneumonectomy and pleuropneumonectomy in patients with pulmonary tuberculosis with multiple/extensive drug resistance (MDR/EDR–TB).

Materials and methods. The results of 118 own operations performed on patients with various forms of pulmonary tuberculosis with multiple/extensive drug resistance (MDR/EDR-TB) treated in our clinic during 2006-2022 were analyzed. Pneumonectomy (PE) was performed in 82 (69.5%) patients, pleuropneumonectomy (PPE) – in 36 (30.5%) patients. Minimally invasive video-assisted surgical procedures (VATS) were used in 5 (4%) patients whom VATS – pneumonectomy was performed: 3 (2.5%) on the right and 2 (1.5%) on the left.

Research results. Among the patients operated on by us surgery treatment was effective in 102 (86.4±3.2%) patients during the observation period of up to 6 years. Postoperative complications developed in 11 (9.3±2.7%) patients: 5 (4.2±1.9%) patients – pleural empyema with bronchial fistula, 2 (1.7±1.2%) patients – early postoperative empyema without bronchial fistula, 4 (3.4±1.7%) – patients with postoperative intrapleural bleeding. 9 (7.6±2.4%) patients were operated on again due to postoperative complications: thoracostomy application with open sanation – 1 patient (0.8±0.8%), staged thoracoplasties – 2 patients (1.7±1.2%), video thoracoscopic sanation of the pleural cavity – 2 patients (1.7±1.2%), removal of intrapleural hematoma – 4 (3.4±1.7%) patients. 5 (4.2±1.9%) patients died after surgery.

Conclusions. Pneumonectomy (PE) and pleuropneumonectomy (PPE) are effective methods of treatment for patients with pulmonary tuberculosis with multiple/extensive drug resistance (MDR/EDR-TB) against the background of complex antituberculosis therapy. According to the data of our clinic, the use of PE or PPE was effective in 86.4% of cases, progression of TB was observed in 9.3% of patients. Making a decision to perform PE or PPE is possible in conjunction with a phthisiologist only after conducting a spiral computed tomography (SCT), which allows detecting small destructive changes in the remaining lung. Performing PE or PPE is possible in the presence of dense foci or small dense tuberculomes in the contralateral lung without signs of destruction, occupying no more than one segment; in all other cases it is more appropriate to perform collapsosurgical interventions (primary thoracoplasty or resection with thoracoplasty). When conducting PE or PPE in patients with MDR/EDR-TB of the lungs, it is mandatory to use one of the methods of additional strengthening of the bronchial stump and prevention of pleural empyema.

Amna Ali, MD
Division of General Surgery, UCSF Fresno, Fresno, California

Shamsuddin Khwaja, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California

Jeffrey Saavedra, MD
CMI Radiology, Fresno, California

Kamell Eckroth-Bernard, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Valley Vascular Surgery Associate, Fresno, California

Usman Javed, MD
The Heart Group, Fresno, California

Chandrasekar Venugopal, MD
CMI Radiology, Fresno, California

Heidi Reich, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California

Habiba Hashimi, MD
Division of General Surgery, UCSF Fresno, Fresno, California

Leheb Araim, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California

Robert Stewart, MD
Division of General Surgery, UCSF Fresno, Fresno, California ; Central California Heart and Lung Surgery, Clovis, California

Lisa Wilkins, NP
Central California Heart and Lung Surgery, Clovis, California

Navjot Janday, NP
Central California Heart and Lung Surgery, Clovis, California

Alex Calkins, NP
Central California Heart and Lung Surgery, Clovis, California

John C Lin, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California

Abstract

There have been significant advances in the technique and application of endovascular repair of thoracic aortic pathology over the past 20 years. The Stanford type A and the complicated type B dissection patients require urgent/emergent intervention.  In the last decade, earlier intervention has been pursued for uncomplicated type B dissections. The INvestigation of STent-grafts in Aortic Dissection (INSTEAD) Long term (XL) study showed that there was significant crossover from medical management to Thoracic EndoVascular Aortic Repair (TEVAR) at year 3, suggesting TEVAR might benefit this population long term.

Today, the application of TEVAR, which was initially designed to address aneurysmal disease, has become a standard and Food and Drug Administrative (FDA) approved management option in dissections.

Currently there are four FDA approved TEVAR devices in the United States for the treatment of the thoracic dissections, namely Gore, Medtronic, Cook, and Terumo.  With each iteration, there are increased opportunities for customization and widespread use in individualized patient’s pathology.  As the technology improves and the feasibility of the grafts expands, the complication rates continue to decline cementing the safety and efficacy of these thoracic aortic grafts. Two rare but catastrophic complications in spinal ischemia and retrograde Stanford type A aortic dissection are further discussed.  With the success of the TEVAR, a new frontier of hybrid aortic surgery has developed.  The debranching of the aortic arch vessels in order to advance the TEVAR proximal landing zones has been aggressively pursued.  With the widespread growth of TEVAR technology it is apparent that complex aortic pathology can be safely repaired endovascularly. 

Adli Azam Mohammad Razi
Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Cardiothoracic Surgery Unit, Department of Surgery, Gleneagles;Hospital Medini, Malaysia

Abstract

Robotic surgery is a platform for minimally invasive thoracic surgery with similar general advantages as in VATS (Video Assisted Thoracic Surgery) including small incisions, faster recovery, minimal blood loss and shorter hospital stay. The extra advantages of using a robotic platform in thoracic surgery include a three-dimensional surgical view, elimination of physiological tremors, and enabling surgical manipulation in a natural orientation because of the presence of forceps that move in the same manner as human wrist joints. These advantages allow more complex procedures to be performed safely and easier technically, thus leading to better outcomes and improvement in the overall result. As a new advance in thoracic surgery, it has challenges that may become the reason why this technique has difficulty being adopted by a number of surgeons including cost, advancement in VATS technique and instrumentation. Despite the challenges, robotic thoracic surgery offers the platform for the expansion and improvement of thoracic surgery. Development in instrument technologies and designs, in addition to progress and interest in other futuristic technology, are notable opportunities for thoracic robotic surgery.

Laura De Donder
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Vicky Maerens
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Heidi Maertens
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Kjell Fierens
Department of General Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Anneleen Stockman
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Stefanie De Buyser
Biostatistics Unit, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium

Cedric Coucke
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Yves Blomme
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.

Abstract

Objective: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest European Society of Vascular Surgery (ESVS) guidelines on the management of atherosclerotic carotid disease, routine patching is preferred to routine primary closure. However, there are no RCT’s evaluating selective patching strategies. This follow-up study aimed to assess long term complication rate and restenosis after carotid endarterectomy with selective patching.
Methods: Two hundred thirteen consecutive carotid endarterectomies over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Patient population consisted of 141 procedures on males and 72 on females with mean age 73 years at the time of surgery (standard deviation (SD) 8.57, range 53-95). There was a follow-up of 89%. Postoperative risk factors were assessed such as hypertension, diabetes mellitus, coronary artery disease and smoking. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after carotid endarterectomy.
Results: Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups’ baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05).

In four cases patients experienced symptoms of cranial nerve damage postoperatively, two in each group. In one of the two cases in each group, the patient fully recovered and the other had persistent complaints (P-value= 1). None of the patients experienced amaurosis fugax during the 5-year follow up period. In five cases a patient had an ipsilateral cerebrovascular thrombosis in the group after patch angioplasty compared to zero in the primary closure group (P-value= .02). In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P-value = .70). One was caused by cerebral hyperperfusion syndrome within one month postoperative after patch angioplasty and none were caused by an ipsilateral ischemic stroke. Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P-value= .43). In twelve cases patients showed a restenosis between 50-70% (6 primary closure and 6 patch angioplasty), none of the patients had high grade restenosis of more than 70%. Patient characteristics did not show a significant effect on long term outcomes. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P-value= .006), restenosis (P-value= .01) and mortality (P-value= .003).

Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected cases. Best medical treatment and especially the use of antihypertensive medication should be emphasized.

Opanasenko Mykola, MD
Professor, chief medical officer, Head of the Department of Thoracic Surgery and Invasive Diagnostic Methods at the State University "National Institute of Phthisiology and Pulmonology FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10.

Tereshkovych Oleksandr, MD.
Deputy chief physician of State University "National Institute of Phthisiology and Pulmonology". FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Konik Bohdan, PhD
Head of the department of surgical treatment of tuberculosis and non-specific diseases of the lungs complicated by purulent-septic infections State Enterprise "National Institute of Phthisiology and Pulmonology" FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Lysenko Volodymyr, Junior Researcher
Department of Thoracic Surgery and Invasive Diagnostic Methods, State University "National Institute of Phthisiology and Pulmonology". F. G. Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Shalahai Serhii, Senior Researcher
Department of Thoracic Surgery and Invasive Diagnostic Methods, State University & National Institute of Phthisiology and Pulmonology". F. G. Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Levanda Larysa
Head of the Department of Anesthesiology, DU "National Institute of Phthisiology and Pulmonology. FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Kalenychenko Maksym, PhD, Researcher
Department of Thoracic Surgery and Invasive Diagnostic Methods, State Institution “National Institute of Tuberculosis and Pulmonology named after F.G. Yanovsky National Academy of Medical Sciences of Ukraine & Kyiv, street Amosova 10

Shamrai Maksym, Anesthetist
Department of anesthesiology, State University & National Institute of Phthisiology and Pulmonology. FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10.

Stepaniuk Alona
Surgeon in the department of surgical treatment of tuberculosis and non-specific diseases of the lungs complicated by purulent-septic infections State Enterprise & National Institute of Phthisiology and Pulmonology & FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Bilokon Serhii, Junior Researcher
Department of Thoracic Surgery and Invasive Diagnostic Methods of the State University & National Institute of Phthisiology and Pulmonology & FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Shestakova Oleksandra, Anesthetist
Department of anesthesiology, State University "National Institute of Phthisiology and Pulmonology". FG Yanovsky NAMS of Ukraine », Kyiv, street. Amosova 10

Abstract

Introduction. Pulmonary tuberculosis is a serious problem as in Ukraine as throughout the world. The number of patients with pulmonary tuberculosis is increasing year by year, which is due to the difficulties in early detection of this disease.

The aim. To determine the effectiveness of surgical treatment of patients with pulmonary tuberculosis by using video-assisted thoracoscopic interventions.

Methods. In the Department of Thoracic Surgery of the State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky NAMS of Ukraine” from 2008 to 2022 140 video assisted lung resections were performed in a planned manner for phthisis-surgical patients. The distribution according to the type of resection intervention was as follows: atypical segmental resection – in 30 (21.4 %) cases, typical segmentectomy – in 50 (35.7 %), lobectomy – in 52 (37.2 %), bilobectomy – in 3 (2.1 %), pulmonectomy – in 5 (3.6 %).

The results. The average duration of operative VATS resection interventions was (75.1 ± 22.3) min., intraoperative blood loss was (85.4 ± 1.6) ml, duration of narcotic analgesics prescription in patients with video-assisted thoracoscopic lung resections was (2.20 ± 0.04) days. Early mobilization of patients recorded in 112 (80.0 ± 3.4) cases. The average length of stay of the patient in the intensive care unit after video-assisted thoracoscopic lung resection was (2.6 ± 0.8) days, length of stay of the patient in the hospital in the postoperative period was (12.4 ± 0.5) days. Intraoperative complications were diagnosed in 7 (5.0 ± 1.8) % of patients. The rate of postoperative complications was 22 (15.7 ± 3.1) % of observation. There was no postoperative mortality after minimally invasive surgical interventions. The overall efficiency of performing video-assisted thoracoscopic lung resections was 97.1 %.

Conclusion. The use of video-assisted thoracoscopic is a convenient, effective and low-traumatic method in the treatment of patients with pulmonary tuberculosis. The overall effectiveness of video-assisted thoracoscopic methods for pulmonary tuberculosis was 97.1 %. An adequate assessment of the possibility of performing video-assisted thoracoscopic and the use of methods to prevent complications ensures a predictable course of the intra- and postoperative periods and increases the effectiveness of surgical interventions.

Giuseppe Mangiameli
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy

Ugo Cioffi
Department of Surgery, University of Milan, Milan, Italy

Marco Alloisio
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy

Federica Carlea
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy

Alberto Testori
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy

Abstract

Castleman’s disease is a benign lymphoproliferative disorder affecting both lymph nodes and extranodal loci. Castleman’s disease can occur in practically any part of the body, but it occurs mainly in the thorax (~70%) followed by the abdomen and pelvis, neck and axilla. Clinically, Castleman’s disease can be classified into a unicentric or multicentric form, depending on the number of lymph nodes involved, and histologically into a hyaline vascular variant, plasma cell, mixed cellular or plasmablastic variant. In this mini-review we briefly report and focus on all clinical thoracic manifestations of Castleman’s disease resuming for each of them the possible strategy of treatment.

Emily M. Mackay, MD, MSc
Division of Thoracic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada

Anna L. McGuire, MD, MSc
Division of Thoracic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada; Division of Thoracic Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; Vancouver Coastal Health Research Institute, Vancouver General Hospital, Vancouver, BC, Canada

Abstract

Non-small cell lung cancer (NSCLC) remains one of the most prevalent cancers worldwide, with high rates of local and distant recurrence limiting survival even after curative-intent surgical resection. Traditional adjuvant chemotherapy benefits only 5% of patients, and as such additional treatment modalities are urgently needed to improve NSCLC patient outcomes. Systemic therapy with PD1 and PDL1 immune check-point inhibitors (ICIs) has emerged as a promising treatment option in many types of solid malignancies, including lung cancer. Encouraging results from immunotherapy trials in metastatic lung cancer populations, and now newer results from ongoing clinical trials in early stage locally advanced lung cancers, suggested an evolving role for perioperative immune checkpoint inhibition in resectable NSCLC. In this review we examine the latest advances in the landscape of clinical trials on immunotherapy in resectable NSCLC. We discuss the key findings and specific clinical challenges related to neoadjuvant administration of these immune therapies in the CheckMate816, Impower030, AEGEAN and KEYNOTE671 phase III clinical trials. The role of adjuvant ICI is also discussed examining the ANVIL, Impower010, and PEARLS trials. By understanding the remaining unanswered questions and clinical dilemmas that exist in this rapidly evolving field for ICIs in early stage NSCLC, clinicians may provide patients options which may markedly improve survival outcomes for this life-threatening disease.

Christopher L. Antonacci, MD, MS, MPH
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

M. Darryl Antonacci, MD
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

William P. Bassett, MD
Eastern Maine Medical Center at Northern Light Health, 489 State Street, Webber West, Suite 340, Bangor, ME 04401

Laury A. Cuddihy, MD
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

Allison R. Haas, RNFA
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

Janet L. Cerrone, PA-C
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

Dominique S. Haoson
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

Randal R. Betz, MD
Institute for Spine & Scoliosis, PA, 3100 Princeton Pike, Lawrenceville, NJ 08648

 

Abstract

Anterior vertebral body tethering (VBT) in growing children has been reported as an alternative to fusion for thoracic idiopathic scoliosis. Anterior scoliosis correction (ASC) is our multi-year, multi-generational advancement upon VBT and is a “de-tethering,” not tethering, procedure. ASC incorporates cords/screws similarly to VBT but is a technique that allows for large derotation, curve correction, and restoration of kyphosis using anterior longitudinal ligament complex release (ligament, annular capsule, and disc). It has been used to treat adolescents with minimal or no growth remaining. In this retrospective IRB-approved analysis, we report outcomes of an early cohort of skeletally maturing/mature (Sanders ≥ 5) patients undergoing ASC.

Methods: Inclusion criteria: patients with AIS, at least one operative curve 35-70°, Sanders ≥ 5, age ≤ 21 years, minimum 2-year follow-up or failure before. Forty-nine patients with 82 treated curves with surgery from January 2015 to December 2017 met the criteria and were reviewed. Mean follow-up was 30.3 months range 24 to 50 months. Average age at surgery was 15.2 years.

Results: The average coronal correction was 65.5% for thoracic curves and 66.7% for lumbar curves. 71.4% of patients with thoracic curves received at least 1 thoracic disc release. Kyphosis (T5-T12) calculated 3D corrected from average 2° pre to 34° post-op. Clinical success (final curve ≤ 30°) was achieved in 45/49 (92%) patients and in 78/82 curves (95%). One unanticipated revision was recommended but not performed.

Conclusion: The 2-4 year results of ASC in maturing and mature patients with AIS demonstrated average curve correction of 65.5% in thoracic and 66.7% in lumbar curves. Clinical success with residual curves ≤ 30° was achieved in 47/49 (96%) of all thoracic curves and 31/33 (94%) of all lumbar curves. Average 3D thoracic kyphosis corrected from 2° pre to 34° post.

M. Darryl Antonacci, MD
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Anthony Yung, MMSc
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA

Ashleigh Kozicz, MPH/PA-C
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Janet Cerrone, PA-C
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Christopher L. Antonacci, MD
Dept. of Orthopaedic Surgery, UConn Health, Farmington, CT, USA

Yashvi Verma
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Madeline Sweeney, APN
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Laury A. Cuddihy, MD
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Randal R. Betz, MD
Institute for Spine & Scoliosis, Lawrenceville, NJ, USA

Abstract

Anterior Scoliosis Correction (ASC) is the proprietary technique of the authors and is an anterior spinal “de-tethering” technique using multiple flexible rod-cords and multiple screw constructs. It is performed through a modified anterior fusion approach that is a muscle-sparing mini-thoracotomy. ASC is the multi-year (since 2013), multi-generational modification of the original anterior vertebral body tethering procedure but includes preservation of the segmental arteries and incorporates multilevel releasing techniques of the contracted anterior longitudinal ligament and annular disc complex. Because of this, ASC, unlike vertebral body tethering, has been shown to derotate the hypokyphotic scoliotic spine effectively towards a more normal thoracic kyphosis and is not restricted to small curves or pediatric patients with growth remaining as is vertebral body tethering.

We retrospectively reviewed all 309 ASC procedures performed between September 2017 and August 2020, and 26 patients met the inclusion criteria (adolescent idiopathic scoliosis and at least a thoracic operative curve with severe coronal curve angles between 66° and 90°, double screw and rod-cord construct, and minimum 2-year follow-up).

The results of ASC on severe curves showed an average curve correction of 78.4% in thoracic and 71.2% in lumbar curves in the instrumented curves. Anterior longitudinal ligament and annular disc complex releases were performed on all patients having thoracic curves to help obtain adequate correction. An average of 4.1 discs per patient were released, all in the thoracic region. Clinical success with residual curves ≤ 35° was 96% (25/26 curves) in all patients and 92.3% in patients with curves ≤ 30° (24/26 curves). Three-dimensional (3D) thoracic kyphosis corrected an average of 39° from preoperative hypokyphosis of -4° to 35° postoperatively. There were no revisions performed in this group of patients.

In conclusion, Anterior Scoliosis Correction has potential expanded indications and increased ability to correct severe curves (> 65°) in patients with adolescent idiopathic scoliosis as compared to vertebral body tethering.

Nikolay Shchapov, MD, PhD
Thoracoabdominal surgery service and emergency surgical care for children, Ilyinskaya Hospital, build. 2, 2, Rublevskoe predmestie st., vil. Glukhovo, Moscow Region, Russia, 143421; Moscow Regional Center for Maternity and Childhood Healthcare, 338A, Oktyabrskiy prosp., Lybertsy, Moscow Region, Russia, 140014

Ekaterina Ekimovskaya, MD, PhD
Surgical Department of Newborns and Infants, The National Medical Research Center of Children’s Health, 2/1, Lomonosovskiy prosp., Moscow, Russia, 119991; Moscow Regional Center for Maternity and Childhood Healthcare, 338A, Oktyabrskiy prosp., Lybertsy, Moscow Region, Russia, 140014

Denis Kulikov, MD
Thoracoabdominal surgery service and emergency surgical care for children, Ilyinskaya Hospital, build. 2, 2, Rublevskoe predmestie st., vil. Glukhovo, Moscow Region, Russia, 143421; Moscow Regional Center for Maternity and Childhood Healthcare, 338A, Oktyabrskiy prosp., Lybertsy, Moscow Region, Russia, 140014

Alexey Mayorov, MD
Blood Gravitational Surgery and Hemodialysis Center, St. Vladimir Children’s Clinical Hospital, Moscow, Russia; Moscow Regional Center for Maternity and Childhood Healthcare, 338A, Oktyabrskiy prosp., Lybertsy, Moscow Region, Russia, 140014

Svetlana Shatova, MD
Pediatric department, MEDSI clinic in Kotelniki, 5, Sosnovaya st., Kotelniki, Lybertsy distr., Moscow Region, Russian, 140055; Moscow Regional Center for Maternity and Childhood Healthcare, 338A, Oktyabrskiy prosp., Lybertsy, Moscow Region, Russia, 140014

Svetlana Sergeyeva, MD
V.F. Voyno-Yasenetsky Scientific and Practical Center of Specialized Medical Care for Children, 38, Aviatorov st., Moscow, Russia, 119620; Moscow Regional Center for Maternity and Childhood Healthcare, 338A, Oktyabrskiy prosp., Lybertsy, Moscow Region, Russia, 140014

Abstract

Conginental duodenal obstruction is a relatively rare malformation. Laparoscopic operation for this condition was described for the first time in 2001, but more than 20 years later, there is still debate over the preferred method of surgical correction. We believe that laparoscopic correction of conginental duodenal obstruction is a safe and feasible method and can be used in premature infants with low body weight.

Materials and Methods: From September 2017 to December 2021, 27 children with conginental duodenal obstruction were treated in our department. We were able to identify the diagnosis in 17 children during the antenatal period, while plain X-ray confirmed postnatal diagnosis. In doubtful cases the contrast fluoroscopy was performed. Four children underwent open correction of the defect via a circumbilical approach, while laparoscopic duodeno-duodenal anastomosis using the Kimura technique was performed in the remaining 23 children.

Results: Intraoperative complication in the form of duct injury was observed in 1 patient with an atypically located Wirsung duct. In the postoperative period, anastomotic failure was noted in 2 children, and perforation of the duodenum was detected in 2 patients. The mortality rate comprised 26%, which was partly attributed to severe concomitant pathologies. The use of prolonged epidural analgesia in combination with laparoscopic surgery provided early weaning from mechanical ventilation and transfer from the intensive care unit. Enteral feeding was initiated on postoperative day 5, and the average length of hospital stay was 29±10.5 days.

Conclusion: There are no limitations to performing laparoscopic correction of congenital duodenal obstruction. When there are accompanying congenital defects, minimally invasive technology allows to perform combined operations on organs of the thoracic and abdominal cavity, which reduces the overall surgical time. In combination with prolonged epidural analgesia, laparoscopic technique reduces the length of stay in the intensive care unit and the need for parenteral nutrition, which ultimately lowers the risk of inflammatory complications and treatment costs.

Angelo Gianni Casalini, MD
Unit of Pulmonology and Thoracic Endoscopy, University Hospital of Parma, Italy.

Pier Anselmo Mori, MD
Unit of Pulmonology and Thoracic Endoscopy, University Hospital of Parma, Italy.

Roberta Pisi, BSc
Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Italy.

Federico Maria Maniscalco, MD
Department of Medicine and Surgery, University of Parma, Italy

Massimo Corradi, MD
Centre for Research in Toxicology (CERT), University of Parma, Italy

Matteo Goldoni, PhD
Department of Medicine and Surgery, University of Parma, Italy

Abstract

A pleural effusion is defined as eosinophilic when eosinophils represent ≥ 10% of the total nucleated cell count, and accounts for approximately 10% of all pleural effusions. The diagnostic significance of eosinophilic pleural effusion has yet to be determined.

Objective and Methods: A retrospective study was conducted on 65 patients with eosinophilic pleural effusion to evaluate the correlation between the percentage of eosinophils present in the pleural fluid and the benign or malignant nature of the effusion. An original aspect of current study was the evaluation of other variables in association with pleural eosinophilia, in particular pleural fluid lymphocytosis (≥ 50%), and the presence or absence of fever.

Results: Data showed the trend towards a decrease in neoplastic incidence with increasing percentages of eosinophilic counts, although this correlation was not statistically significant. The presence of fever correlated with low incidence of neoplasms (10% of neoplastic effusions in patients with fever) and was the most significant variable (p=0.001), with a Negative Predictive Value of neoplastic disease of 90%, with sensitivity 92.6% and specificity 47.4%.

When evaluated together with fever, eosinophils increased their discriminating sensitivity to the benign or malignant nature of the effusion but lost in specificity.

When evaluated as absence or presence of lymphocytosis (≥50% lymphocytes), associated with eosinophilia, lymphocytes were significantly associated with the neoplastic nature of the effusion.

Conclusions: the study showed that the finding of eosinophilic pleural effusion should not be considered an indicator of benignity of the effusion; the association of other parameters with eosinophilia, lymphocytosis of the pleural fluid and fever can provide more precise prognostic indications; a high percentage of eosinophils, the absence of lymphocytosis and the presence of fever would seem to be associated with a low probability of a neoplastic nature of the effusion.

M. Darryl Antonacci, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ

Anthony Yung, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ

Christopher L. Antonacci, MD, MPH
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ

Laury A. Cuddihy, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ

Randal R. Betz, MD
Work Performed at the Institute for Spine and Scoliosis, Lawrenceville, NJ

Abstract

Adolescent idiopathic scoliosis (AIS) can continue to progress after skeletal maturity. Once the progression is severe, posterior spinal fusion (PSF) is the gold standard for surgical treatment. While effective in achieving curve correction, PSF is associated with many problems, including loss of spinal flexibility, uncorrected sagittal deformity, and adjacent segment disease. We present a case of a 50-year-old woman with a documented 38º thoracic curve as a late teen who experienced curve progression after skeletal maturity to >70 ° and underwent Anterior Scoliosis Correction (ASC), a motion-preserving scoliosis correction surgery. Her progressive curve improved from 71º Lenke 1A main thoracic curve to 28°, with a 59% correction being maintained within 5° (33°) at 7 years. She also obtained a 50% correction of her compensatory lumbar curve and correction of hypokyphosis from 2.4° to 23° at 7 years. Along with improvement of her thoracic kyphosis, her lumbar lordosis decreased to a normal range of 60° from 70°, giving her better overall alignment. This case report suggests that motion preserving surgical treatment may be considered for some select adult patients with progressive scoliosis.

Juliana Matiello, MD, PhD
Radiation Oncologist Oncology Thoracic Group Santa Casa de Porto Alegre, Brazil Head Radiation Oncology Service Hospital Ana Nery

Maiara Dalenogare
Medical Physicist Radiation Oncology Service Santa Casa de Porto Alegre, Brazil Federal University of Rio Grande do Sul, Porto Alegre, Brazil

Danilo Cortesi Berton, MD, PhD
Pneumonology Professor Division of Pulmonology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

Abstract

Radiotherapy is the most common local treatment for lung cancer. The spectrum of its use ranges from the treatment of early-stage tumors in patients who are not candidates for surgery to the treatment of advanced, unresectable tumors and, very frequently, of metastatic lesions. With great interest, radiotherapy has also been currently cited as a source of neoantigens, stimulating the immune system and enhancing the effect of immunomodulatory drugs. However, the side effects of irradiation on the lung parenchyma and on the immune system can turn it into a hidden foe, impairing patients’ quality of life and survival. Pneumonitis and immunosuppression are two of the side effects of radiotherapy that best exemplify this hidden damage. Studies have shown decreased survival in patients who develop radiation pneumonitis or have a large volume of immune tissue irradiated. Irradiating less lung tissue will reduce damage to lung function and loss of immune cells. However, this alone is not sufficient for dose protection in lymphoid tissue, given the circulation of lymphoid cells in the great vessels and heart and their production in thoracic vertebral bone marrow. Identifying the optimal total dose and the most appropriate daily dose to reduce damage and boost the immune system is the target of our investigations. Although we still do not have an optimal algorithm for dose, fraction, and cost-effectiveness for radiation doses delivered to healthy tissues, we know which path to take.

Martínez-Hernández martínez Lucia
Hospital Español, Infectology

Choi Su Jung
Hospital Español, Internal Medicine

Medina-García Gerardo
Hospital Español, Internal Medicine

Lorenzo-Silva José Manuel
Hospital Español, Thoracic Surgery

López-Enríquez Claudia
Hospital Español, Infectology

Donís-Hernández José
Hospital Español, Infectology

Abstract

To date, few report cases of spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema without any cause of trauma have been observed in patients with COVID-19 pneumonia. We present a case of a 66-year-old male patient who developed such complication on day 19 of hospitalization, without requiring non-invasive or invasive ventilator. CT thorax scan revealed widespread bilateral ground glass opacities with pneumothorax, pneumomediastinum, and subcutaneous emphysema, which were resolved totally on the following 29 days. We highlight preexisting mechanisms for pulmonary air-leak syndrome and importance of prompt recognition to establish adequate therapy in patients with COVID-19 pneumonia.

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