Management of thoracic outlet syndrome in patients with hemodialysis access

Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access.

Advanced lung cancer patient benefits from minimally invasive costal resection and reconstruction: an effective palliative approach for costal metastasis

We hereby describe the resection and reconstruction of a rib infiltrated by a lung cancer metastasis. Despite prior radiation therapy aimed at mitigating pain from rib infiltration in a stage IV non-small cell lung cancer patient, results were unsatisfactory. Employing a minimally invasive palliative strategy, we executed a successful operation to address this issue. This technique presents a viable alternative for patients experiencing recurrent pain post radiation therapy.

Predictors of the need for rib resection in minimally invasive retroperitoneal approach for oblique lateral interbody fusion at upper lumbar spine (L1-2 and L2-3)

BACKGROUND

This study aimed to identify factors that can predict the need for rib resection in a minimally invasive, oblique retroperitoneal approach for upper lumbar interbody fusion (OLIF at L1-3) using modern tubular retractors.

METHODS

Eighty-six patients, who underwent L1-2 and/or L2-3 OLIF at a single institution, were included. Decision for rib resection was made through intraoperative fluoroscopic view (true lateral view of the desired level). Patients were divided into two groups according to rib resection (rib resection and non-rib resection groups). Baseline demographics, surgical and radiographic data, including coronal/sagittal spinopelvic parameters and perioperative complications, were compared between the groups. Logistic regression analysis was performed to identify the factors predicting the need for rib resection.

RESULTS

The study cohort comprised 31 patients in the rib resection group and 55 patients in the non-rib resection group. There was no significant inter-group difference in terms of the baseline demographics. A total of 79% patients undergoing the two-level (both L1-2 and L2-3) procedures were rib-resected, while 81.6% of the patients undergoing the L2-3 level alone were not rib-resected. Endplate injuries occurred more commonly in the non-rib resection group (3% vs. 14%). Pleural laceration was observed in 6% of the patients in the rib resection group. The mean T10-L2 kyphosis was larger in the rib resection group than in the non-rib resection group (14.9° vs. 6.6°, P = 0.031). Multivariate logistic regression analysis identified the following independent predictors of the need for rib resection: an L1-2 inclusive procedure; T10-L2 kyphosis > 15.9°; and the apex of the coronal curve located above L2.

CONCLUSION

The need for rib resection should be expected when performing L1-2 inclusive procedure. Even in the L2-3 alone case, aggressive decision-making for intraoperative rib resection might be required for an appropriate tubular retractor position, especially for patients with thoracolumbar kyphosis and apex vertebra of the major coronal curve located above L2.

A new sign of the slipping rib syndrome?

The slipping rib syndrome is characterized by burning pain in the lower thorax and upper abdomen, often disabling, caused by hypermobility of the costal cartilage with entrapment of the intercostal nerve. The syndrome is often underdiagnosed. The diagnosis is clinical and the definitive treatment is surgical, with an excellent result for pain relief. Based on the observation of 4 cases undergoing rib resection for SRS, we noticed a new possible sign of the disease. Our patients showed less thickness of the ipsilateral rectus abdominis muscle on ultrasound of the abdomen. The aim of this study is to demonstrate this sign in the diagnosis of SRS, to make this disease more recognizable and treatable.

Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet

OBJECTIVE

Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy.

METHODS

We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection.

RESULTS

During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months.

CONCLUSIONS

Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.

Surgical management of empyema thoracis - experience of a decade in a tertiary care centre in India

Introduction and purpose

Empyema thoracis (ET) is defined as the accumulation of pus in the pleural cavity. Early stages of ET are treated medically and the late stages surgically. Decortication, thoracoplasty, window procedure (Eloesser flap procedure) and rib resections are the open surgical procedures executed. There are no strict guidelines available in developing nations to guide surgical decision-making, as to which procedure is to be followed.

Methods

Details of all adult patients treated surgically for ET, between the years 2009 and 2019, and maintained in a live database in our institute, were retrieved and analysed. Medically managed patients were excluded.

Results

There were 437 patients in the study. The average age was 38 years. There was right side preponderance with a male:female ratio of 5:1. Tuberculosis was the commonest aetiology identified in 248 (57%) patients and diabetes was the commonest co-morbidity present in 97 (22%) patients. There was a higher incidence of a window procedure (WP) in tubercular patients 145 (59%). Only 26 (14%) of the non-tubercular patients underwent a WP. Post-operative complications were persistent air leak in 12 (6%) patients and premature closure of a window in 7 (4%) patients. There were 4 (0.9%) post-operative mortalities.

Conclusion

Surgical management of late stages of ET provides good results with minimal morbidity and mortality. In developing nations like India, the high incidence of tuberculosis and late presentations make the surgical management difficult and the strategies different from those in developed nations. No clear guidelines exist for the surgical management of ET in developing nations. There is a need for a consensus on the surgical management of empyema in such countries.

Thoracoscopic resection of parosteal lipoma of the rib using orthopedic electric micro drill

Parosteal lipoma derived from the rib is extremely rare and is usually resected through open thoracotomy despite its benign nature. A 33-year-old man who had no symptoms was referred to our hospital for treatment of a 30-mm chest wall mass that has slightly increased in size during 2 years of follow-up. En bloc resection of the tumor with parts of the 3rd and 4th ribs was performed through a complete thoracoscopic approach using orthopedic electric micro drill. This was the first report on a case of parosteal lipoma of the rib that was resected by a complete thoracoscopic procedure.

Associations between treatment, scoliosis, pulmonary function, and physical performance in long-term survivors of sarcoma

PURPOSE

Longer survival for children with sarcoma has led to the recognition of chronic health conditions related to prior therapy. We sought to study the association of sarcoma therapy with the development of scoliosis.

METHODS

We reviewed patient demographics, treatment exposures, and functional outcomes for patients surviving >10 years after treatment for sarcoma between 1964 and 2002 at our institution. The diagnosis of scoliosis was determined by imaging. Functional performance and standardized questionnaires were completed in a long-term follow-up clinic.

RESULTS

We identified 367 patients, with median age at follow-up of 33.1 years. Scoliosis was identified in 100 (27.2%) patients. Chest radiation (relative risk (RR), 1.88 (95% confidence interval (CI), 1.21-2.92), p < 0.005) and rib resection (RR, 2.64 (CI, 1.79-3.89), p < 0.0001) were associated with an increased incidence of scoliosis; thoracotomy without rib resection was not. Of 21 patients who underwent rib resection, 16 (80.8%) had the apex of scoliosis towards the surgical side. Scoliosis was associated with worse pulmonary function (RR, 1.74 (CI, 1.14-2.66), p < 0.01) and self-reported health outcomes, including functional impairment (RR, 1.60 (CI, 1.07-2.38), p < 0.05) and cancer-related pain (RR, 1.55 (CI, 1.11-2.16), p < 0.01). Interestingly, pulmonary function was not associated with performance on the 6-min walk test in this young population.

CONCLUSIONS

Children with sarcoma are at risk of developing scoliosis when treatment regimens include chest radiation or rib resection. Identification of these risk factors may allow for early intervention designed to prevent adverse long-term outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors at risk of developing scoliosis may benefit from monitoring of pulmonary status and early physical therapy.

Infantile cranial fasciitis: case-based review and operative technique

BACKGROUND

Cranial fasciitis (CF) is an uncommon benign primary lesion of the skull that typically affects the pediatric age group. Due to the rarity of CF, no prospective studies exist. Earliest description of this condition dates to 1980. The limited scientific and clinical literature regarding CF is dominated by case reports. For these reasons, questions pertaining to the true incidence, genetic risk factors, prognosis, and long-term outcome remain unanswered.

DISCUSSION

Clinically, CF presents as a firm, painless, growing scalp mass that is typically not considered in the differential diagnosis. Preoperative pathognomonic signs and symptoms are absent, and imaging features are often nonspecific. Treatment is typically through complete surgical resection, at which time histopathological examination confirms the diagnosis of CF. Reconstruction of the skull defect in the child is critical. Autograft techniques help maintain a rigid construct that integrates with the native skull while preserving its continued ability to grow. Generally, a good outcome is observed with complete resection.

EXEMPLARY CASE

We report a case of CF in an infant with emphasis on operative nuances and early follow-up results.

CONCLUSION

CF is a rare fibroproliferative disease that has a poorly defined incidence and long-term follow-up. Due to its locally invasive nature and nonspecific presentation, CF is often difficult to differentiate from malignancies and infections. Complete surgical resection is the best approach for diagnosis and cure. Its occult clinical presentation often allows it to achieve considerable growth, leaving a sizeable skull defect following resection. Since CF presents in the pediatric population, allograft reconstruction is preferred over titanium mesh or other synthetic materials to allow osseous integration and continued uninterrupted skull growth.

Scoliosis after chest wall resection

BACKGROUND DATA

There has been an increased focus on the role of rib abnormalities in the development of scoliosis. Rib resection may influence the development of scoliosis. Although scoliosis has been identified in patients after thoracotomy, most of the currently available information is from case reports.

METHODS

We examined records of 37 patients who underwent a chest wall or rib resection for rib lesions at our institution during the period of 1992 to 2005. Adequate data was available in 21 patients. We gathered data on demographic information, location of resection, and changes in curvature after resection based on radiograph or scout CT films at the latest follow-up appointment.

RESULTS

Fourteen of 21 patients developed scoliosis with a mean Cobb angle of 25.8° (10°-70°). Eleven of these 14 patients had a progressive spinal deformity after chest wall resection with an average change in curvature of 29° (10°-70°). Eight of those 11 developed a convex toward the resection, while 3/11 developed a convex away from the resection. Seven of the eight patients with resections that included a rib superior to the sixth rib developed scoliosis, while four of 13 with resections below the sixth rib developed scoliosis.

CONCLUSION

Patients who have had a rib or chest wall resection are at risk for developing scoliosis, particularly if the resection is performed above the sixth rib.