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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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Park JM, Son J, Kim DH, Son BS. A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation. Yonsei Med J 2023; 64:730-737. [PMID: 37992745 PMCID: PMC10681828 DOI: 10.3349/ymj.2023.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 11/24/2023] Open
Abstract
PURPOSE Clamshell incision offers excellent exposure and access to the pleural spaces and is a standard incision for lung transplantation. However, due to its high sternal complication rate, the clamshell incision is considered a procedure that requires improvement. In this study, we aimed to investigate the outcomes of transverse sternotomy with clamshell incision in comparison to sternum-sparing bilateral anterolateral thoracotomy (BAT). MATERIALS AND METHODS In total, 134 bilateral sequential lung transplants were performed from May 2013 to June 2022. The clamshell incision was used between May 2013 and December 2017, and the BAT was introduced in January 2018. Thirty-four patients underwent clamshell surgery, and 100 patients underwent BAT. We retrospectively compared patient characteristics and perioperative and postoperative outcomes between the two groups. RESULTS The clamshell group required an operation time of 745.18±101.76 min, which was significantly longer than that of the BAT group at 669.90±134.09 min (p=0.003). The mechanical ventilation period after surgery was 17.26±16.04 days in the clamshell group, significantly longer than the 11.35±12.42 days in the BAT group (p=0.028). Intensive care unit stay was also significantly longer in the clamshell group (21.54±15.23 days vs. 15.03±14.28 days; p=0.033). In-hospital mortality rates were 26.5% in the clamshell group and 22.0% in the BAT group. CONCLUSION Less-invasive lung transplantation via sternum-sparing BAT is a safe procedure with low morbidity and favorable outcomes. Preventing sternal instability enables more stable breathing after surgery, earlier weaning from mechanical ventilation, and faster recovery to routine activities.
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Affiliation(s)
- Jong Myung Park
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
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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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