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PubMed2007

Cytokine response is lower after lung volume reduction through bilateral thoracoscopy versus sternotomy.

BACKGROUND: Lung volume reduction surgery performed through bilateral video-assisted thoracoscopy (BVATS) was associated in the National Emphysema Treatment Trial with a statistically significant reduction in intensive care unit days, failure to wean, hospital stay, and cost, and earlier recovery compared with median sternotomy. Studies comparing other minimally invasive techniques with "open" procedures, including pulmonary lobectomy, have demonstrated reduced serum proinflammatory mediators postoperatively. We measured these levels after lung volume reduction surgery through BVATS and sternotomy. METHODS: Serum cytokine levels were measured by radioimmunoassay in 9 consecutive, steroid-free patients undergoing sternotomy and lung volume reduction surgery and 6 undergoing BVATS and lung volume reduction surgery. The groups were not statistically different with respect to age, partial pressure of arterial carbon dioxide, percent forced expiratory volume in 1 second, percent residual volume, percent total lung capacity, diffusion capacity of the lung for carbon monoxide, 6-minute walk, or apical perfusion fraction. Proinflammatory interleukin 6 and interleukin 8 and antiinflammatory interleukin 10 were evaluated preoperatively and postoperatively on days 1, 4, and 5. Clinical data were prospectively collected. RESULTS: There were no major postoperative complications or deaths. Interleukin 6 levels were lower in the BVATS than the sternotomy group (p = 0.016 by repeated measures analysis of variance). Interleukin 8 levels were lower in the BVATS group at most postoperative time points, but there were no significant differences in interleukin 8 or interleukin 10 levels between the sternotomy and BVATS groups at any individual time point or by analysis of variance. CONCLUSIONS: Use of a BVATS approach to lung volume reduction surgery is associated with reduced postoperative release of proinflammatory cytokines compared with a sternotomy approach. This may account for the reduction in recovery time and some measures of postoperative morbidity seen with the BVATS approach.

Aged↗

PubMed2005

The role of median sternotomy in resections for large hepatocellular carcinomas.

BACKGROUND: The aim of this study was to identify the role of median sternotomy in the hepatic resection of large hepatocellular carcinomas (HCCs). METHODS: From 1992 to 2002, 26 patients who underwent hepatectomy for large HCCs greater than 10 cm in diameter were divided into 2 groups according to the type of incision performed: with median sternotomy (10 patients) or without median sternotomy (16 patients). RESULTS: Median sternotomy was performed for 3 patients with tumor thrombus extending into the right atrium and for 7 patients with inadequate exposure of the hepatic veins and suprahepatic vena cava. In these 7 cases, the tumors were located mainly at the upper part of the right lobe in 4 patients and the upper part of the left lobe in 3 patients. Median sternotomy was performed in 6 of 7 patients whose tumor was located in segments 2, 4, 7, and 8, and was greater than 16 cm. No significant differences were found in the intraoperative parameters of blood transfusion, ischemic time, area of the cut surface, and operation time. CONCLUSIONS: Median sternotomy may be suitable for use as an approach for large HCCs greater than 16 cm, which are located at the upper part of the liver.

Carcinoma, Hepatocellular↗

PubMed2001

Ministernotomy versus full sternotomy in congenital heart defects: a prospective randomized study.

BACKGROUND: Although the ministernotomy is extensively used in the repair of congenital heart defects all over the world, whether this approach has additional advantages over the conventional full sternotomy is not well established. This prospective study was designed to evaluate the effects of lower ministernotomy in the repair of congenital heart defects. METHODS: One hundred patients who underwent repair of atrial or ventricular septal defects were randomly divided into two groups: lower ministernotomy group (n = 50), and full sternotomy group (n = 50). The clinical indexes of each procedure were recorded and analyzed. RESULTS: The age, sex, and types of cardiac defects were comparable between the two groups. Ischemic times, bypass times, intensive care unit stay, and ventilation duration were similar in both groups. The procedure time (from skin to skin) was longer in the lower ministernotomy group than in the full sternotomy group (p < 0.001). There was less drainage in the lower ministernotomy group than in the full sternotomy group for the first 24 hours after operation (186 +/- 99 mL/m2 versus 237 +/- 134 mL/m2, p = 0.03) but no significant difference in transfusions between the two groups. The hospital stay was shorter in the lower ministernotomy group than in the full sternotomy group (6.5 +/- 1.2 days versus 7.5 +/- 1.8 days, p = 0.02). CONCLUSIONS: Ministernotomy is as safe and effective as a full sternotomy in the repair of simple congenital heart defects in older children and adults. Furthermore, this small incision reduces the postoperative drainage, shortens hospital stay, and provides better cosmetic results. Operative times are longer.

Adolescent↗

PubMed1986

Comparison of median sternotomy and thoracotomy for resection of pulmonary metastases in patients with adult soft-tissue sarcomas.

Thoracotomy and median sternotomy have both been advocated for resection of pulmonary metastases, and the advantages of each approach remain disputed. Patients with adult soft-tissue sarcomas undergoing resection of pulmonary metastases at the National Cancer Institute were studied retrospectively to assess the results of each surgical approach. Between 1981 and 1984, 65 patients underwent 78 sternotomies (7 lobectomies, 71 wedge resections); a mean of 9.5 nodules were resected per patient (range, 1 to 61). Resection of all nodules was accomplished in 60 of 71 explorations (84%) in patients with documented metastases. Benign lesions were found during 7 explorations (9%). Thirteen of 30 patients (43%) with unilateral metastases on linear tomography (LT), 45% (9 of 20) of patients with unilateral metastases on computed tomography (CT), and 38% (5 of 13) of patients with unilateral metastases on both CT and LT had bilateral metastases at sternotomy. Survival by type of incision was compared for 84 patients who underwent complete resection of their metastases (42 by sternotomy and 42 by thoracotomy); the minimum follow-up was two years. The groups did not differ significantly with respect to prognostic variables (tumor doubling time, disease-free interval, or number of nodules resected). There was no significant difference in actuarial survival between the two groups. The complication rate was 15% for the sternotomy group and 10% for the thoracotomy group (difference not significant). There were no operative deaths. Median sternotomy results in detection of unsuspected bilateral metastases and avoidance of a second operative procedure, but it does not increase operative morbidity or mortality or compromise overall patient survival.

Adult↗

PubMed1998

S-shaped in comparison to L-shaped partial sternotomy for less invasive aortic valve replacement.

OBJECTIVE: Evaluation of less invasive aortic valve replacement to minimize surgical trauma and achieve a better postoperative quality of life. METHODS: Thirty-three patients had aortic valve replacement using a 4-6 cm small incision and partial sternotomy only. Partial sternotomy was performed proximal (16), S-shaped (14) or horizontal (3). Access for cardiopulmonary bypass was via sternotomy (24) or the right femoral vessels (9). Patient age was 58+/-13 years, 21 had aortic stenosis and 12 aortic incompetence. RESULTS: Surgical exposure was sufficient and allowed for uncomplicated AVR in all patients. Mechanical valves (20), conventional bioprostheses (3), stentless bioprostheses (9) or a homograft (1) were implanted. Crossclamp time was not prolonged in comparison to the conventional technique. Intensive care stay and hospital stay were 1 and 10 days, respectively. One patient had to be reoperated for paravalvular leakage, two patients (horizontal sternotomy) had sternal dehiscence. Postoperative pain was low in most patients. CONCLUSION: Less invasive aortic valve replacement is feasible with good functional results. The S-shaped sternotomy approach is advantageous whereas the horizontal sternotomy is no longer performed due to a high rate of instability. This new technique will be further evaluated in comparison to the conventional approach.

Aortic Valve↗

PubMedDate not supplied

Avoidance of full-sternotomy: effect on inflammatory cytokine production during cardiopulmonary bypass in rats.

BACKGROUND AND AIM OF THE STUDY: Although open heart operations via a mini-sternotomy or mini-thoracotomy are considered "less invasive" cosmetically and are hopeful for early social recovery, clinical experiences have not shown less invasiveness toward systemic inflammatory response, because of the wide variety of patients and operative procedures encountered. We examined the effect of a mini-sternotomy on an inflammatory response during a cardiopulmonary bypass (CPB) procedure performed in rats. METHODS: Thirty-two adult Sprague-Dawley (SD) rats, each of which underwent a 120-minute CPB, were randomly divided into four groups according to the method of exposing the pericardial cavity; no sternotomy (Group N [0 cm], n = 8), right para-sternal thoracotomy (Group P [2 cm], n = 8), lower mini-sternotomy (Group M [2 cm], n = 8), and full-sternotomy (Group F [4 cm], n = 8). Blood samples were obtained (1) just prior to the initiation of CPB, and then (2) 30, (3) 60, and (4) 120 minutes after the initiation of CPB. RESULTS: Thirty minutes after the initiation of CPB, there were significant differences in plasma interleukin [IL]-6 levels between groups, except for Groups P and M; whereas at 60 minutes the only significant difference occurred between Groups N and F, and at 120 minutes there were no significant differences between any of the groups. Further, plasma IL-8 levels were not significantly different at each sampling point between all of the groups. CONCLUSIONS: These results first demonstrate experimentally that the avoidance of a full-sternotomy can be considered a less invasive strategy in terms of reducing the systemic inflammatory response that accompanies a shorter CPB duration.

Animals↗

PubMed2005

Patient attitudes to sternotomy and thoracotomy scars.

BACKGROUND: There are no data comparing patient attitudes to sternotomy and thoracotomy scars following surgery for congenital heart disease (CHD). METHODS: Two hundred and one patients with a scar from CHD surgery (105 sternotomy, 36 thoracotomy, and 60 both scars) had a structured interview to explore attitudes to their scar. RESULTS: Comparable proportions of each group reported that they did not like or hated their scar (23/105 [22 %] sternotomy, 9/36 [25 %] thoracotomy, 17/60 [28 %] both scars). Significantly more patients stated that they where embarrassed by and/or their choice of clothing was affected by a thoracotomy scar (20/36, 56 %) than those with a sternotomy scar (36/105, 34 %), p = 0.04. This was also seen when comparing sternotomy alone with both scars (36/105 [34 %] vs. 34/60 [57 %], p = 0.008). CONCLUSIONS: Adults who have undergone surgery for CHD are more likely to have a negative attitude to a thoracotomy than a sternotomy scar. Before a change in surgical approach is considered based on patient preferences, the acceptability and psychological impact of the different scars following surgery needs formal study.

Adult↗

PubMed1998

Median sternotomy: the preferred incision for resection of lung metastases.

OBJECTIVE: To describe our experience with median sternotomy for resection of lung metastases and to assess whether computer tomography (CT) accurately predicts the number and extent of lung metastases. DESIGN: Retrospective case record study. SETTING: University hospital/Cancer Centre, The Netherlands. SUBJECTS: 78 patients with pulmonary metastases from various histological types of tumours who were operated on through a median sternotomy during the 10-year period January 1985-January 1995. INTERVENTION: Median sternotomy for resection of lung metastases with the intention to cure. Extension of the incision in case of extended disease. MAIN OUTCOME MEASURES: Presence of unilateral or bilateral metastases in relation to preoperative CT. RESULTS: 78 patients underwent a total of 82 sternotomies. CT did not accurately diagnose the extent of disease in 38 patients (49%). In 72 cases metastases were excised. In 58 patients (81%) histological examination showed tumour-free margins microscopically. 36 patients had bilateral metastases. CT showed unilateral disease in 49 patients. 14 (29%) had bilateral involvement. 4 patients required lobectomy and in two patients anterolateral extension of the sternotomy was necessary. Eleven patients (15%) developed minor complications. There was no operative mortality. CONCLUSION: Bilateral staging and finding of occult metastases, complete surgical clearance in a one stage procedure, and lower morbidity are the reasons that we suggest that median sternotomy is the procedure of choice of resection of pulmonary metastases. For eligible patients the choice of surgical approach should not be made conditional on the results of CT alone.

Adolescent↗

PubMed1995

Sternotomy approach for the modified Blalock-Taussig shunt.

BACKGROUND: Since 1990, sternotomy has been the preferred approach for construction of a modified Blalock-Taussig shunt (MBTS) at Children's Hospital, Boston, Mass. In retrospect, we sought to test the hypothesis that this approach yields less mortality and morbidity than the traditional thoracotomy approach. METHODS AND RESULTS: One hundred four primary MBTSs with polytetrafluoroethylene grafts were constructed in patients from January 1988 through December 1992. Fifty-two shunts were constructed by thoracotomy approach and 52 by sternotomy approach. Fifteen of the thoracotomy patients were less than one month of age (8 less than 7 days), while 36 of the sternotomy patients were less than 1 month of age (20 less than 7 days). There were 10 shunt failures and 3 hospital deaths in the thoracotomy group and 4 shunt failures with 6 hospital deaths in the sternotomy group. The overall hospital mortality rate for the group was 8.7% (9 of 104). The operative route was not a significant predictor of hospital mortality (P = .30). However, there was a significant difference between the two operative approaches in shunt failure, with shunts that were created by thoracotomy four times more likely to fail than those created by the sternotomy route (odds ratio, OR, 3.88; 95% CI, 1.01 to 15.03; P = .049). The side of the shunt was also a significant predictor of failure with left-side MBTSs foru times more prone to failure (OR, 4.02; 95% CI, 1.19 to 15.25; P = .025). CONCLUSIONS: The sternotomy route is technically less challenging and is associated with fewer shunt failures than the classic thoracotomy approach. The potential theoretical disadvantages of this method for future sternal reentry for subsequent procedures was not apparent but requires prospective analysis.

Adolescent↗

PubMed2004

Inferior partial sternotomy for surgical closure of isolated ventricular septal defects in children.

BACKGROUND: Surgical closure of isolated ventricular septal defect (VSD) through partial inferior sternotomy offers the advantages of a much shorter, cosmetically superior skin incision, potentially improved sternal stability, a lower rate of infection, and less postoperative pain. We report our technique and results of use of inferior partial sternotomy for closure of isolated VSD in children. PATIENTS AND METHODS: From July 2002 to July 2003, 24 consecutive patients with a median age of 4.5 months (range, 1 month-4.5 years) underwent partial inferior sternotomy for isolated VSD closure. The length of the incision ranged from 4 to 6 cm. Special features of the approach included T incision of the lower sternum (from the fourth intercostal space to the xiphoid), establishment of cardiopulmonary bypass with central cannulation, aortic cross-clamping, and cardioplegic arrest. All VSDs were approached through right atriotomy. Perimembranous VSDs were exposed after detachment of the anterior leaflet of the tricuspid valve and were closed with a continuous suture. Muscular VSDs were approached directly. Perioperative and postoperative echocardiographic findings were available for all patients. Follow-up was complete. RESULTS: There was no mortality or significant surgical morbidity. Median cross-clamping and cardiopulmonary bypass times were 43 and 103 minutes, respectively. All patients were in sinus rhythm. Perioperative and postoperative echocardiography confirmed the absence of any residual defects in perimembranous VSDs and the presence of a trace residual VSD in 4 patients with muscular VSDs. Optimal healing of the partial sternotomy was obtained in all patients. CONCLUSIONS: Inferior partial sternotomy is less invasive than and cosmetically superior to full sternotomy. It provides excellent results when applied to isolated VSD with standard surgical techniques.

Child, Preschool↗

PubMed1999

Technical adjuncts in beating heart surgery comparison of MIDCAB to off-pump sternotomy: a meta-analysis.

OBJECTIVES: The technical aspects of minimal invasive surgery are discussed, together with a comparison of off-pump MIDCAB with off-pump sternotomy, with special respect to outcomes of death, infarct and anastomoses. METHODS: Technical aspects of beating heart surgery are described under the headings: Trauma; Access; Stabilisation; Ischaemia; Haemostasis; Suturing; and Circulatory support. Data from papers and meetings on minimal invasive surgery were collated to September 1998 and correlated with the unit of origin. Percentage figures were back calculated to provide an actual number from which a new data base was obtained relevant to the reporting incidence. For statistical analysis a Chi squared test with Yates correction was used. RESULTS: Sixty-three centres reported 3304 cases of MIDCAB surgery (M) and 21 centres reported over 3060 cases of off-pump surgery through a sternotomy (S). There was no difference in early or late death rates between the two groups (1.6% M:2.2% S). There was a higher infarct rate with MIDCAB (2.9% M: 1.45% S; P < 0.03). The occlusion and stenosis rates for MIDCAB were 3.9 and 6.6% whilst for sternotomy off-pump they were 4.9 and 1.4%. The stenosis difference was significant at the P < 0.001 level. A combined occlusion and stenosis rate showed a higher incidence with MIDCAB (10.5%), than sternotomy 6.4% (P < 0.08). Four major series showed comparative data before and after stabiliser usage in MIDCABs. The stenosis rate was significantly reduced with stabilisation from 9.6 to 3.7% (P < 0.002) as was the combined occlusion and stenosis rate from 16 to 5.0% (P < 0.0001). In the total series there was no significant difference in length of stay (4.6 days), incidence of atrial fibrillation (9%), or between conversion to sternotomy(MIDCAB group) or to bypass (sternotomy group) (5%) between the two groups (M and S). Grafting the right coronary artery by MIDCAB produced worse results than for the left anterior descending artery (LAD). CONCLUSIONS: There is an important failure rate with beating heart surgery; stabilisers reduce this risk and are essential tools in both MIDCAB and beating heart surgery and encourages the further use of minimally invasive approaches.

Coronary Angiography↗

PubMed1999

Comparison of self-reinforced poly-L-lactide and steel wire in fixation of sternotomy in rabbits.

BACKGROUND AND AIMS: To investigate the healing of sternotomies fixed with biodegradable self-reinforced poly-L-lactide (SR-PLLA) wire and comparing it with steel wire fixation. MATERIAL AND METHODS: Sixteen rabbits (15 Chinchilla and one New Zealand White rabbit) were operated on. Two parallel holes of 1.5 mm in diameter were drilled in the sternum at the level of the second and third rib and similar holes of 0.8 mm were drilled at the level of the third and fourth rib. A transverse sternotomy was created between both drill hole pairs. The sternotomy with larger drill holes was fixed with 1.1-mm thick SR-PLLA wire. The sternotomy between the smaller drill holes was fixed using 2.0 steel wire. The animals were sacrificed at 2, 7, 26 and 52 weeks postoperatively and specimens were taken, radiographed and studied by both light and scanning electron microscopy. RESULTS: One rabbit died at four months postoperatively as a result of gastrointestinal problems. No other complications were seen. The SR-PLLA wire was slowly degraded. There was no disturbance of bone healing. The implants were surrounded by a fibrous tissue capsule, which also contained chronic inflammatory cells. Both SR-PLLA and steel wires provided sufficient fixation security. No differences in the healing of the sternotomies were observed between SR-PLLA and steel wire fixation. CONCLUSIONS: SR-PLLA wires are biocompatible and useful for sternotomy fixation. They may be suitable for use in clinical applications.

Absorbable Implants↗

PubMed1975

Surgical considerations in patients undergoing repeat median sternotomy.

A retrospective review of 122 repeat median sternotomy incisions in 100 consecutive patients was made to evaluate complications and management. Eighty-one patients had one repeat sternotomy, )6 had two repeat sternotomies, and 3 had three repeat sternotomies. All had valve procedures in the past and were reoperated upon for progressive rheumatic valvular disease or for complications related to the prostheses. Complications included operative hemorrhage in 8 patients, postoperative hemorrhage in 2, seroma in 4, and dehiscence, wound infection, and hematoma in 1 patient each. The most serious complication was hemorrhage and was the cause of the only operative death. Seven other patients survived hemorrhage encountered during repeat sternotomy. Control of massive hemorrhage during repeat sternotomy has been possible due to an organized approach to the patient with adhesions from previous surgery.

Adolescent↗

PubMedDate not supplied

Role of video-assisted thoracic surgery for the treatment of myasthenia gravis: extended thymectomy by median sternotomy versus the thoracoscopic approach with sternal lifting.

The role of video-assisted thoracic surgery (VATS) thymectomy is still being studied, and many surgeons remain skeptical of the value of this recent option. We made a retrospective evaluation to ascertain whether VATS-extended thymectomy is as reliable as standard median sternotomy in the treatment of myasthenia gravis (MG) and whether the endoscopic procedure presents any advantages for patients. Eighteen consecutive patients requiring extended thymectomy for MG were treated between April 1997 and September 2003 at our hospital. Nine patients received VATS-extended thymectomy, and the remaining nine patients received standard extended thymectomy by sternotomy. In the VATS group, the anterior mediastinal space was well visualized by sternal lifting. The mean operative time was 268.3 +/- 51.1 minutes in the VATS group and 177.3 +/- 92.5 minutes in the sternotomy group. Operative time was significant longer in the VATS group than in the sternotomy group (P < 0.05). The mean operative bleeding was 68.6 +/- 47.8 ml in the VATS group and 154.1 +/- 109.0 ml in the sternotomy group. Operative bleeding was significantly less in the VATS group than in the sternotomy group (P < 0.05). There was no significant difference between the two groups with regard to postoperative duration of chest tube or the level of serum C-reactive protein on the first operative day. There was a downward trend in nicotinic acetylcholine receptors antibody levels after thymectomy compared with before thymectomy in both groups. VATS thymectomy should be considered a valid alternative to the established approaches aimed at achieving a "curative thymectomy" in patients with MG.

Adolescent↗

PubMed1998

Lung volume reduction surgery: a cost and outcomes comparison of sternotomy versus thoracoscopy.

It remains unknown whether it is better to perform lung volume reduction surgery (LVRS) through video-assisted thoracoscopy (VATS) or sternotomy. This study compares both approaches in terms of surgical and patient outcomes as well as the associated costs. All patients undergoing LVRS from 1995 to 1997 at one institution by a single surgeon (PFW) were investigated. Preoperative, postoperative, and cost data were obtained from medical and financial records. A total of 42 patients with severe emphysema underwent LVRS (19 via sternotomy and 23 via thoracoscopy). Both groups were comparable preoperatively. Comparison of intraoperative times revealed VATS takes longer to perform (sternotomy, 118 +/- 29 minutes; thoracoscopy, 168 +/- 20 minutes). Postoperatively, the sternotomy patients had more days on the ventilator, more days in the intensive care unit, more days with an air leak, and longer hospital stays. In both groups, the majority of patients reported improvement in oxygen dependence as well as quality of life. Neither surgical approach conferred any long-term medical advantage; however, the average total hospital costs and charges were reduced in the VATS group (average cost: VATS, $27,178; sternotomy, $37,299). This study concludes that 1) LVRS seems to be beneficial for selected patients with end-stage emphysema; 2) postoperative morbidity and length of hospital stay are decreased in the VATS group; 3) long-term improvement in postoperative pulmonary function is not influenced by surgical approach; and 4) the overall charges and costs of the VATS approach is less than that of sternotomy.

Aged↗

PubMed1997

Anterior thoracic corpectomy without sternotomy: a strategy for malignant disease of the upper thoracic spine.

BACKGROUND: With increasing frequency, spine surgeons are being asked to provide decompression and stabilization in patients with spinal metastases. While no region of the spine is easily treated, the upper thoracic spine is perhaps the least accessible. Traditional approaches to this region involve either thoracotomy or at least limited sternotomy. The authors present an approach to anterior pathology of the upper thoracic spine that obviates the need for sternotomy. METHODS: Within the past two years, two patients with cervicothoracic metastases underwent anterior decompression and fusion without sternotomy. In both patients, the bodies of C7, T1, and T2 were removed. While both patients were prepared and draped for sternotomy, each required a neck dissection only. In both patients, left-sided incisions were made along the leading edge of the sternocleidomastoid. The platysma was divided with the overlying skin. With further dissection, the strap muscles were tagged and divided approximately one centimeter above their sternal attachments. The loose areolar tissue of the superior mediastinum was then bluntly dissected. Along the entire length of the incision, the vascular plane medial to the carotid sheath was developed to facilitate exposure of the anterior spine. A Farley-Thompson retractor system was then employed to retract and protect the superior mediastinal structures. With this exposure, corpectomies were carried out using a high speed drill. Fusion was accomplished through insertion of Steinmann pins into the adjacent intact bodies above and below. This was followed by application of methyl methacrylate. Both patients had immediate postoperative stability with preservation of spinal cord function. Both patients subsequently underwent removal of dorsally located tumor with posterior fusion. CONCLUSIONS: The goal of cancer surgery is to provide for increased functional survival without undue morbidity. The authors feel that when possible, the pain of sternal and clavicular osteotomies should be avoided. The described approach works well in conjunction with a methyl methacrylate/Steinmann pin construct. Because of the intact sternum, the surgeon has a downward angle to access the superior endplate of T3. With adequate soft tissue dissection and retraction as described, however, T3 and perhaps even T4 are easily accessible. While this downward angle would likely not permit an anterior plating procedure, it lends itself nicely to Steinmann pin/methyl methacrylate fusion and spares the patient the pain and potential morbidity of sternotomy.

Breast Neoplasms↗

PubMed2006

Retrosternal goiter: the need for median sternotomy.

INTRODUCTION: The aim of this study was to analyze the features of patients with goiter who underwent thyroidectomy via a cervical incision and a median sternotomy in Khartoum. METHODS: A total of 267 thyroidectomies were performed in Khartoum Teaching Hospital during the period from January 2002 to December 2003. There were 40 patients with evidence of retrosternal goiter (15%). Of those 40 patients, 13 had clinical and radiologic evidence of deep retrosternal extension of the goiter possibly necessitating sternotomy. Only 9 of the 13 patients actually required sternotomy, which accounted for 3.4% of all thyroidectomies performed (n = 267). The clinical, radiologic, and pathologic findings of those 9 sternotomy patients were analyzed and compared to those of the 258 patients who underwent cervical thyroidecomy. RESULTS: Total thyroidectomy was undertaken in all nine patients. Six of them had retrosternal extension on the right side of the mediastinum, and three had bilateral extension. Seven patients had symptoms of respiratory distress, and two were asymptomatic. The duration of the goiter ranged between 7 and 30 years. The chest radiograph and computed tomography scan revealed that the retrosternal part was below the level of the aortic knuckle at the tracheal bifurcation in all cases. The histopathology revealed a simple multinodular goiter in eight of the nine patients (89%) and in one patient with papillary carcinoma. Five of the nine patients underwent intraoperative prophylactic tracheostomy due to tracheomalacia. CONCLUSIONS: A long-standing goiter with deep (below the aortic knuckle) mediastinal extension and tracheal space compromise can be postulated to increase the likelihood of sternotomy.

Adult↗

PubMed2004

Comparison of limited and full sternotomy in aortic valve replacement.

OBJECTIVE: The practice of minimally invasive valve surgery remains controversial. The aim of this study was to evaluate the technical feasibility and postoperative course of aortic valve replacement through limited upper sternotomy compared to conventional full sternotomy. METHODS: From May 1998 to August 2000, we performed 24 cases of isolated aortic valve replacements through the limited upper sternotomy approach (group M). During the same period, 18 patients received isolated aortic valve replacements through the conventional full sternotomy approach (group C). Operation duration, postoperative course and laboratory data were compared between the two groups. RESULTS: All patients received a valve replacement with a prosthetic valve. There was no significant difference between the two groups in mean aortic cross-clamping time, mean cardiopulmonary bypass time or mean operation duration (skin to skin). No patient required blood transfusion. Patients in the group M were extubated earlier, with less postoperative blood loss and discharged earlier after the operation than those in group C. On the first postoperative day, the peak level of lactic acid dehydrogenease was significantly lower in the group M than those in group C. CONCLUSION: Limited upper sternotomy for aortic valve replacement resulted in shorter operation duration and minimized operative risks for the patients. We believe this method brings not only cosmetic benefits but also improved postoperative course.

Adult↗