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Buero A, Lopez SO, Lyons GA, Pankl LG, Young P, Chimondeguy DJ. First Rib Resection Using Videothoracoscopy in Patients With Vascular Thoracic Outlet Syndrome. EJVES Vasc Forum 2024; 62:15-20. [PMID: 39309754 PMCID: PMC11415954 DOI: 10.1016/j.ejvsvf.2024.06.004] [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: 02/15/2024] [Revised: 05/20/2024] [Accepted: 06/25/2024] [Indexed: 09/25/2024] Open
Abstract
Objective Thoracic outlet syndrome (TOS) comprises a series of signs and symptoms produced by compression of neurovascular structures in any of the anatomical spaces of the thoracic outlet. First rib resection is a therapeutic alternative to decompress the structures of the thoracic outlet at the costoclavicular space. Traditional surgical approaches include transaxillary, supraclavicular, and infraclavicular access. The objective was to describe the surgical experience and follow up results of first rib resection using video assisted thoracoscopic surgery (VATS) in patients with vascular TOS. Methods Observational descriptive study based on a retrospective single centre analysis of a prospective database. Patients diagnosed with vascular TOS who underwent VATS first rib resection from January 2017 to December 2023 were included. The diagnosis for each subtype was based on the criteria defined in the standards of the American Society for Vascular Surgery in TOS. Among other things, the response to initial anticoagulation, peri-operative data, complications, symptom improvement, duration of post-operative anticoagulation, and symptom recurrence were investigated. Results Twenty nine patients diagnosed with vascular TOS who underwent VATS first rib resection, three of whom had bilateral procedures, were included. The total number of costal rib resections performed was 32 (31 venous TOS and one arterial TOS). The mean age was 29.1 ± 10.4 years and mean hospital stay was 2.7 ± 1.2 days. There were neither conversions to open surgery nor intra-operative complications, but there were two major post-operative complications (6.25%). No recurrences were detected during midterm follow up (median of 17.9 months, interquartile range 7.3, 45). Conclusion VATS first rib resection is a safe and feasible procedure. Unlike traditional approaches, this procedure allows physicians to make the resection under complete vision of the anatomical structures of the thoracic outlet reducing intra-operative complications and, if necessary, entire rib resection can be performed.
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Affiliation(s)
- Agustín Buero
- Thoracic Surgery Department, Hospital Británico, Buenos Aires, Argentina
| | | | - Gustavo A. Lyons
- Thoracic Surgery Department, Hospital Británico, Buenos Aires, Argentina
| | - Leonardo G. Pankl
- Thoracic Surgery Department, Hospital Británico, Buenos Aires, Argentina
| | - Pablo Young
- Internal Medicine Department, Hospital Británico, Buenos Aires, Argentina
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Belyak EA, Lazko FL, Sufianov AA, Paskhin DL, Prizov AP, Lazko MF, Sagdiev RK, Zagorodniy NVE. Extra-Articular Endoscopic BP Decompression-Surgical Technique. Arthrosc Tech 2024; 13:102938. [PMID: 38835473 PMCID: PMC11144805 DOI: 10.1016/j.eats.2024.102938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/31/2023] [Indexed: 06/06/2024] Open
Abstract
We describe all-endoscopic brachial plexus (BP) decompression. Surgery is performed with the patient in the beach-chair position with the usual arthroscopic instruments and pump. The first step is to create 2 portals at the area of the coracoid process and decompress the infraclavicular part of the BP at area of thoracic aperture and coracoid. The second step includes performing 2 portals at supraclavicular fossa and performing decompression of BP at interscalene space. The postoperative period includes a short period of sling immobilization (3-5 days), immediate passive motion after surgery, and active motion after removal of the sling.
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Affiliation(s)
- Evgeniy Aleksandrovich Belyak
- Moscow state city hospital in honor of Buyanov V.M., Docent of Peoples' Friendship University of Russia (RUDN University) Moscow, Russia, Moscow, Russia
| | - Fjodor Leonidovich Lazko
- Moscow state city hospital in honor of Buyanov V.M., Docent of Peoples' Friendship University of Russia (RUDN University) Moscow, Russia, Moscow, Russia
| | - Albert Akramovich Sufianov
- Department of Neurosurgery, I.M. Sechenov First State Medical University (Sechenov University), Moscow, Russia
- Educational and Scientific Institute of Neurosurgery, Peoples' Friendship University of Russia (RUDN University), Moscow, Russia
- Federal Centre of Neurosurgery, Moscow, Russia
| | - Dmitriy Lvovich Paskhin
- Moscow state city hospital in honor of Buyanov V.M., Docent of Peoples' Friendship University of Russia (RUDN University) Moscow, Russia, Moscow, Russia
| | - Alexey Petrovich Prizov
- Moscow state city hospital in honor of Buyanov V.M., Docent of Peoples' Friendship University of Russia (RUDN University) Moscow, Russia, Moscow, Russia
| | - Maxim Fjodorovich Lazko
- Moscow state city hospital in honor of Buyanov V.M., Docent of Peoples' Friendship University of Russia (RUDN University) Moscow, Russia, Moscow, Russia
| | - Ranel Khamitovich Sagdiev
- Department of Neurosurgery, I.M. Sechenov First State Medical University (Sechenov University), Moscow, Russia
| | - Nikolay Vasil Evich Zagorodniy
- Educational and Scientific Institute of Neurosurgery, Peoples' Friendship University of Russia (RUDN University), Moscow, Russia
- Orthopedic Department of Federal State Budgetary Institution of the Ministry of Health of the Russian Federation National Medical Research Center for Traumatology and Orthopedics named after N.N. Priorov, Moscow, Russia
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Reyes M, Alaparthi S, Roedl JB, Moreta MC, Evans NR, Grenda T, Okusanya OT. Robotic First Rib Resection in Thoracic Outlet Syndrome: A Systematic Review of Current Literature. J Clin Med 2023; 12:6689. [PMID: 37892829 PMCID: PMC10607688 DOI: 10.3390/jcm12206689] [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: 09/05/2023] [Revised: 10/14/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Thoracic outlet syndrome (TOS) involves the compression of neurovascular structures in the thoracic outlet. TOS subtypes, including neurogenic (nTOS), venous (vTOS), and arterial (aTOS) are characterized by distinct clinical presentations and diagnostic considerations. This review explores the incidence, diagnostic challenges, and management of TOS with a focus on the innovative approach of Robotic First Rib Resection (R-FRR). Traditional management of TOS includes conservative measures and surgical interventions, with various open surgical approaches carrying risks of complications. R-FRR, a minimally invasive technique, offers advantages such as improved exposure, reduced injury risk to neurovascular structures, and shorter hospital stays. A comprehensive literature review was conducted to assess the outcomes of R-FRR for TOS. Data from 12 selected studies involving 397 patients with nTOS, vTOS, and aTOS were reviewed. The results indicate that R-FRR is associated with favorable intraoperative outcomes including minimal blood loss and low conversion rates to traditional approaches. Postoperatively, patients experienced decreased pain, improved function, and low complication rates. These findings support R-FRR as a safe and effective option for medically refractory TOS.
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Affiliation(s)
- Maikerly Reyes
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Sneha Alaparthi
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| | - Johannes B. Roedl
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA;
| | - Marisa C. Moreta
- Department of Rehabilitation Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA;
| | - Nathaniel R. Evans
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| | - Tyler Grenda
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| | - Olugbenga T. Okusanya
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
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Liu B, Gao S, Wu Q, Li H, Zhang G, Fu J. A case report of robotic-assisted resection of large fibrous benign tumor of second rib. J Cardiothorac Surg 2022; 17:329. [PMID: 36539826 PMCID: PMC9769036 DOI: 10.1186/s13019-022-02041-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surgical resection is the most effective curative management of benign rib tumors and carries an excellent prognosis. Due to complex anatomy and narrow field, higher rib resection is technically demanding and requires extensive dissection. CASE PRESENTATION We report a case of second rib tumor resection performed transthoracic under Da Vinci robot assistance. A 32-year-old male complained about increasing pain in the left anterior chest wall. After 3D reconstruction of CT, it showed a well-circumscribed fusiform lesion with a multi-component structure. Measured 17 × 6 × 4 cm and extended into the chest cavity to the depth below the pectoralis minor muscle. The patient underwent robotic-assisted trans-thoracic second rib resection. At four weeks of outpatient follow-up, the patient reported no pain and uncomplicated wound healing. CONCLUSION This minimally invasive approach offers optimal visualization and tissue manipulation while dramatically decreasing the possibility of collateral damage, hence ensuring fast function recovery. To the best of our knowledge, these kinds of procedures are rarely reported in detail.
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Affiliation(s)
- Bohao Liu
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Shan Gao
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Qifei Wu
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Haijun Li
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Guangjian Zhang
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
| | - Junke Fu
- grid.452438.c0000 0004 1760 8119Department of Thoracic Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277# Yanta West Road, Xi’an, 710061 Shaanxi China
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A clinical case of a combined endoscopic treatment: brachial plexus decompression in the thoracic aperture and subacromial spacer implantation. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract109942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Thoracic outlet syndrome compression of the brachial plexus in the area between the clavicle and the first rib is a commonly spread and important pathology. It occurs, as usual, after a trauma or due to an anatomical malformation of this area. Thoracic outlet syndrome can be combined with a shoulder joint pathology. In the case of a conservative treatment's failure, the standard surgical procedure is decompression of the brachial plexus in the thoracic aperture. This procedure is usually done via an open approach. The development of the endoscopic surgical technique of decompression allows reducing the risk of complications and recurrences, improving the cosmetic result and relieving the rehabilitation period. Clinical case description: A 73-year-old female patient with a clinical picture of posttraumatic brachial plexopathy and a massive shoulder rotator cuff tear. The patient underwent a conservative treatment for 6 months after the trauma without a significant improvement. To confirm the diagnosis, ENMG and an ultrasound investigation of the brachial plexus, as well as MRI of the shoulder joint were performed. Simultaneous shoulder joint arthroscopy with subacromial spacer implantation and brachial plexus decompression in the thoracic aperture were performed to the patient. According to the VAS-scale (Visual Analogue Scale), the severity of pain syndrome before the surgery was 10 cm, while 6 months after the surgery, it decreased to 1 cm. According to the DASH scale (Disabilities of the Arm, Shoulder, and Hand), the dysfunction of the of shoulder joint before the surgery was 76 points, while 6 months after the surgery, it decreased to 12 points. The range of motion in the shoulder joint before the surgery was as follows: flexion 105, abduction 95, external rotation 15, which increased to 160, 165, and 45, respectively, 6 months after the surgery. Conclusion: The results allow us to characterize the method of simultaneous shoulder joint arthroscopy and endoscopic decompression of the brachial plexus in the thoracic aperture as a low-traumatic and effective technique. The technique provides complete brachial plexus decompression in the thoracic aperture which promotes restoration of the function of the upper extremity and shoulder joint, and elimination of pain syndrome from the upper extremity area.
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Boglione M, Ortíz R, Teplisky D, Giuseppucci C, Korman L, Reusmann A, Barrenechea M. Surgical treatment of thoracic outlet syndrome in pediatrics. J Pediatr Surg 2022; 57:29-33. [PMID: 34563357 DOI: 10.1016/j.jpedsurg.2021.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/27/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
AIM Thoracic outlet syndrome (TOS) is a condition that occurs when the cervical neuro-vascular bundle becomes compressed at one of the three narrow areas of the thoraco-cervico-axillary region. Conservative management is the first line of treatment. Patients who do not respond to conservative management should be treated surgically. The aim of this review is to present our experience with the surgical management of TOS in pediatric patients. METHODS We retrospectively reviewed the outcomes of all patients with TOS operated at our Hospital between 2001 and 2020. We collected all demographic data, clinical features, imaging data, type of operation performed, intraoperative findings, complications and recurrence. RESULTS We operated 9 patients within the study period. The median age at surgery was 14 (7 to 17) years. A transaxillary approach was used in 7 patients and a supraclavicular approach in 2. There was only one minor intraoperative complication (violation of the pleural space). There were no postoperative complications. The median length of stay was 3 (2 to 4) days. All patients were extubated in the operating room. Two patients developed symptoms on the contralateral side. One of these underwent a successful contralateral transaxillary Roos operation. The follow-up was 4 months to 20 years. All patients are asymptomatic. CONCLUSION We believe that the Roos operation is a safe and effective treatment with excellent long-term outcomes for children with TOS that fail conservative management.
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Affiliation(s)
- Mariano Boglione
- General Surgery, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.
| | - Ramiro Ortíz
- General Surgery, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Darío Teplisky
- Interventional Radiology, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Carlos Giuseppucci
- General Surgery, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Luciano Korman
- General Surgery, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Aixa Reusmann
- General Surgery, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Marcelo Barrenechea
- General Surgery, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
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Surgical Approaches for Thoracic Outlet Syndrome: A Review of the Literature. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022. [PMID: 37521542 PMCID: PMC10382894 DOI: 10.1016/j.jhsg.2022.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Thoracic outlet syndrome (TOS) is caused by entrapment of the neurovascular bundle in the interscalene, costoclavicular, or subpectoral minor space. Compression in the interscalene or costoclavicular space with the first rib and scalene muscle leads to vascular and neurogenic TOS, whereas compression in the subpectoral minor space leads to pectoralis minor syndrome. Various surgical approaches exist for the treatment of TOS. The introduction and development of surgical approaches have minimized surgical invasiveness and complications. The reported approaches include transaxillary, supraclavicular, infraclavicular, posterior, combined transaxillary and supraclavicular, combined supraclavicular and infraclavicular (paraclavicular), endoscopic-assisted transaxillary, and video-assisted thoracoscopic approaches. In this review, we summarize the reported surgical approaches for TOS treatment, in terms of the history of the approach, surgical procedure, advantages and disadvantages, clinical outcomes, and complications. An adequate excision of compression structures, including the first rib and scalene muscles, provides satisfactory outcomes regardless of the approach selected, whereas an inadequate release of compression structures leads to failed or recurrent outcomes. Reducing the risk of complications is the most important aspect of TOS management. Surgery should be performed safely, with sufficient resection of compression structures. Additionally, the approach should be selected based on the surgeon's skill, surgeon's preferences, surgical invasiveness, cosmetic appearance, and the presence of special equipment, as well as other advantages and disadvantages of each approach.
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8
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Nuutinen H, Kärkkäinen JM, Kimmo M, Voitto A, Teemu R, Petri S, Janne P. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6545787. [PMID: 35262705 PMCID: PMC9252101 DOI: 10.1093/icvts/ivac040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Henrik Nuutinen
- Department of Surgery, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
- Corresponding author. Henrik Nuutinen, Kuopio University Hospital, Department of Surgery. PL 100, 70029 Kuopio, Finland. e-mail:
| | | | - Mäkinen Kimmo
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Aittola Voitto
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Saari Petri
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Pesonen Janne
- Department of Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland
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Nuutinen H, Kärkkäinen JM, Mäkinen K, Aittola V, Saari P, Pesonen J. Long-term outcome over a decade after first rib resection for neurogenic thoracic outlet syndrome. Interact Cardiovasc Thorac Surg 2021; 33:734-740. [PMID: 34148096 DOI: 10.1093/icvts/ivab172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/14/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim was to determine long-term outcomes over a decade after first rib resection (FRR) in patients with neurogenic thoracic outlet syndrome (NTOS). A secondary aim was to investigate correlation of residual rib stump with long-term symptoms. METHODS This ambispective cohort included patients who underwent transaxillary FRRs for NTOS between 1998 and 2007. Short-term outcomes at 3-month clinical follow-up were retrospectively collected from medical records. Patients who agreed to participate in the study were invited to a long-term clinical follow-up in 2019. Disabilities of Arm, Shoulder, and Hand Score and Cervical Brachial Symptom Questionnaire were used. A chest X-ray limited to a clavicular projection was taken, and the length of the residual first rib was measured. RESULTS Twenty patients {mean age 41.8 [standard deviation (SD): 10.3 years]} who underwent 27 FRRs participated in the study. The mean follow-up time was 14.9 (SD: 3.6) years. Excellent or good recovery was noted after 16 (59.3% of operated arms) operations in the short-term follow-up and 22 (81.5%) operations in the long-term follow-up. No reoperations were necessary for residual symptoms. The mean Cervical Brachial Symptom Questionnaire score was 26.7 (SD: 28.2) (maximum 120), and the Disabilities of Arm, Shoulder, and Hand Score was 21.1 (SD: 18.4) (maximum 100) points. Twenty-six patients (96.3%) had a noticeable residual first rib stump. The mean length of the residual first rib was 28.9 (SD: 9.5) mm. More than 30-mm rib stump did not indicate a worse long-term outcome. CONCLUSIONS This study showed good long-term outcome without symptom recurrence after FRR for NTOS. In most patients, after surgery, quality of life and ability to work improved. Residual rib stump length was not associated with the treatment outcome.
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Affiliation(s)
- Henrik Nuutinen
- Department of Surgery, Kuopio University Hospital, University of Eastern, Kuopio 70029, Finland
| | | | - Kimmo Mäkinen
- Heart Center, Kuopio University Hospital, Kuopio 70029, Finland
| | - Voitto Aittola
- Heart Center, Kuopio University Hospital, Kuopio 70029, Finland
| | - Petri Saari
- Department of Radiology, Kuopio University Hospital, Kuopio 70029, Finland
| | - Janne Pesonen
- Department of Rehabilitation Medicine, Kuopio University Hospital, Kuopio 70029, Finland
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Abstract
Minimally invasive surgical approaches to the treatment of thoracic outlet syndrome (TOS) will become increasingly common as more surgeons gain experience in thoracoscopic and robotic technique. Robotic surgery may be more technically advantageous because of improved visualization and maneuverability of wristed instruments. Longer-term outcome data are necessary to definitively establish the equivalency or superiority of minimally invasive TOS compared with open surgery in the treatment of TOS.
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Affiliation(s)
- Christina L Costantino
- Department of Thoracic Surgery, Massachusetts General Hospital, Founders House, 265 Charles Street, FND-7, Boston, MA 02114, USA
| | - Lana Y Schumacher
- Department of Thoracic Surgery, Massachusetts General Hospital, Founders House, 265 Charles Street, FND-7, Boston, MA 02114, USA.
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Panda N, Phillips WW, Geller AD, Lipsitz S, Colson YL, Donahue DM. Supraclavicular Approach for Neurogenic Thoracic Outlet Syndrome: Description of a Learning Curve. Ann Thorac Surg 2020; 112:1616-1623. [PMID: 33275934 DOI: 10.1016/j.athoracsur.2020.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/12/2020] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The supraclavicular exposure represents an alternative approach for thoracic outlet decompression in neurogenic thoracic outlet syndrome with unique access to neurovascular structures. We aimed to evaluate the learning curve for this approach and associated patient outcomes. METHODS Patients undergoing first-time, unilateral, supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome were included. Cumulative-sum and linear-spline-regression analyses were used to determine the operative time learning curve. Patients were consecutively organized into early (learning phase) and late (competency) cohorts. Primary endpoints were the operative time learning curve operation number and association of this learning curve on differences in self-reported postoperative symptomatic improvement between early and late cohorts, adjusting for American Society of Anesthesiology classification, body mass index, previous treatment (opioid/neuropathic medication/botulinum-injection), and length of stay. RESULTS Among 114 patients, learning curve analyses showed decreasing operative times, plateauing at the 51st operation (ß = -1.63, 95% confidence interval [-2.30, -0.95], P < .001). No periprocedural differences existed between early (operations 1-50) and late (operations 51-114) cohorts. Self-reported 90-day outcomes were similar in early and late cohorts (odds ratio [OR]: 1.60 [0.65, 3.95], P = .31). Mediators of poor self-reported outcomes included increasing American Society of Anesthesiology classification (OR 0.21 [0.08, 0.54], P = .001), failed preoperative botulinum injection (OR 0.15 [0.03, 0.65], P = .01), and increased length of stay (OR 0.40 [0.22, 0.73], P = .003). CONCLUSIONS The learning curve for supraclavicular thoracic outlet decompression in neurogenic thoracic outlet syndrome occurred after 51 operations with a trend towards improved 90-day self-reported outcomes from the early to late phases. These findings, along with mediators of poorer outcomes, may aid surgeons in adopting a new approach and counseling patients on expected outcomes.
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Affiliation(s)
- Nikhil Panda
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - William W Phillips
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Abraham D Geller
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yolonda L Colson
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dean M Donahue
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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12
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Shi J, Hsin M. Commentary: Do Robots Do it Better? Semin Thorac Cardiovasc Surg 2020; 32:1121-1122. [PMID: 32569646 DOI: 10.1053/j.semtcvs.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jianxin Shi
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Michael Hsin
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong.
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13
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Stilo F, Montelione N, Benedetto F, Spinelli D, Vigliotti RC, Spinelli F. Thirty-year experience of transaxillary resection of first rib for thoracic outlet syndrome. INT ANGIOL 2019; 39:82-88. [PMID: 31814380 DOI: 10.23736/s0392-9590.19.04300-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years. METHODS A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates. RESULTS One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%). CONCLUSIONS In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.
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Affiliation(s)
- Francesco Stilo
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | - Nunzio Montelione
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy -
| | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical, Dental Sciences and Morphofunctional Imaging, G. Martino Policlinic Hospital, University of Messina, Messina, Italy
| | - Domenico Spinelli
- Unit of Vascular Surgery, Department of Biomedical, Dental Sciences and Morphofunctional Imaging, G. Martino Policlinic Hospital, University of Messina, Messina, Italy
| | - Rossella C Vigliotti
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy.,Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Francesco Spinelli
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
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