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PubMed2003

A new technique for the treatment of delayed sternotomy healing: the vacuum therapy.

BACKGROUND: The treatment of nonhealing and infected sternotomies after cardiac surgery is a challenging task, with its increased rates of mortality, morbidity, and costs. Local vacuum therapy (V.A.C. system) allows treatment of local infections, thanks to continuous aspiration and the sealed dressing that stimulates granulation tissue formation. The purpose of this clinical investigation was to evaluate vacuum therapy in cardiac surgery for achieving healing of delayed sternotomy closure after cardiac surgery. MATERIALS AND METHODS: From January 1998 to December 2002, 7 patients who underwent coronary artery bypass surgery under cardiopulmonary bypass by median sternotomy approaches presented a nonhealing infected sternal surgical wound that was treated with local vacuum therapy. Aspiration maintained between -125 mm Hg and -200 mm Hg was carried out on the entire surface of the wound with a sponge connected hermetically to an aspiration system. The treatment was associated with antibiotic therapy adapted to the results of bacteriological studies of the aspirates. RESULTS: All patients with delayed sternotomy closure healed in approximately 8 weeks (2-12 weeks) with the exception of one patient who died of multiorgan failure after a satisfactory muscular pectoral flap. Treatment was possible with vacuum therapy alone (n = 2), with vacuum therapy in association by second intention with a skin graft (n = 1), or both with a muscular pectoral flap (n = 4). Sternal stability appears to be an important factor for achieving satisfactory and complete healing. CONCLUSIONS: This new therapy offers an alternative to the classic treatment of infected sternotomies in cardiac surgery, especially in preparing rewiring and muscular flaps for complicated cases with sternal instability or alone. The treatment must be instituted early to be more effective.

Aged↗

PubMed2006

[Aortic valve replacement through a partial sternotomy].

BACKGROUND: Instead of a median sternotomy which has been accepted as the standard approach to cardiaovascular surgery, we have selected a partial sternotomy as a minimally invasive surgery since 1997. Every technique and device must be reevaluated because the entire heart cannot be easily assessed. METHOD: In this paper we reported the pitfalls and results of 108 cases of aortic valve replacement through an upper and lower partial sternotomy. Single surgeon had used the single technique through the same operation field from 1997 to 2005. RESULTS: Mortality rate was 1.9% (2 patients). Aortic cross clamp time was a little longer in this series than in the conventional median sternotomy group. There were no differences in operating time, pumping time, intubation duration or bleeding. ICU stay and hospital stay were shorter in this series than in the conventional sternotomy group. The operating time was shorter in the regurgitation group than in the stenosis group. There were no differences in pumping time, intubation duration, bleeding, ICU stay or hospital stay. CONCLUSION: The minimally invasive cardiac surgery for the aortic valve replacement could be routinely and safely indicated.

Aortic Valve↗

PubMed1990

Surgical approach to atrial septal defect in the female. Right thoracotomy versus sternotomy.

Repair of atrial septal defect (ASD) remains a high-benefit, low-risk procedure due to technologic improvements. From July 1981 to December 1986, 35 females (age, 7 months to 28 years) had repair of ASD; 20 by right thoracotomy and aortic cannulation (group 1) and fifteen by median sternotomy (group 2). In general, right thoracotomy was applied to patients with secundum ASD two years or older and without associated lesions, while median sternotomy was applied to patients with ostium primum lesions and/or associated lesions. Patients or their families perceived the cosmetic results superior to the right thoracotomy approach over the median sternotomy. We feel that a right thoracotomy and aortic cannulation is effective in females (2 years and older) with secundum ASD for a superior cosmetic result over median sternotomy. However, females with ostium primum and/or associated lesions should undergo median sternotomy for better cardiac access and safety.

Adolescent↗

PubMedDate not supplied

Wound infection following early repeat sternotomy for postoperative bleeding. An experience utilizing intraoperative irrigation with povidone iodine.

A prospective observational study of median sternotomy wound infection was carried out in two consecutive groups of unselected patients undergoing early repeat sternotomy for postoperative haemorrhage. In Group A the pericardial cavity and sternotomy wound layers were irrigated with aqueous povidone iodine prior to repeat closure, while Group B did not receive povidone iodine. No median sternotomy infections were recorded in Group A compared to 5 cases in Group B (0 out of 22 vs 5 out of 21 patients, p less than 0.05). Amongst the patients with wound infection, three developed sternal dehiscence and mediastinitis with one death. The data suggests that povidone iodine irrigation may be effective in reducing wound infection in patients undergoing early repeat sternotomy after cardiac surgery.

Aged↗

PubMed1993

Closure of partial median sternotomy with absorbable sutures: a practical and safe option.

A technique for the closure of upper median sternotomy with absorbable polyglycolid acid sutures is described. In a consecutive series of 130 refixations, no major complications occurred. After a mean follow-up period of 66 +/- 61 months, the long-term results concerning sternotomy closure were determined in 86 patients: 84 (98%) sternotomies were completely consolidated, in 75 cases (87%) without any dislocation and in nine cases (11%) with a minor dislocation in the transverse osteotomy. In two patients (2%) who had received postoperative radio- and chemotherapy, an isolated pseudarthrosis of the transverse osteotomy was observed, whereas the median sternotomy was consolidated completely. As a result of our clinical experience, we consider the closure of partial upper sternotomy with absorbable polyglycoid acid sutures as a practical and safe technique.

Absorption↗

PubMed1998

Approach for primary mitral valve surgery: right anterolateral thoracotomy or median sternotomy.

BACKGROUND AND AIMS OF THE STUDY: Although both right anterolateral thoracotomy and median sternotomy have been used for mitral valve surgery (repair/replacement), the latter approach is considered standard for primary mitral valve surgery. We hypothesized that primary mitral valve surgery, if performed through a right anterolateral thoracotomy, would not only be better accepted cosmetically by patients, but also make redo surgery through a median sternotomy easy and trouble free from re-entry bleeding. METHODS: A right anterolateral thoracotomy was used for primary mitral valve surgeries in 52 patients (group A; 22 males, 30 females) of mean age 30.3 +/- 09.14 years (range: 14 to 50 years). Equal numbers of cases operated on during the same period by via median sternotomy were selected retrospectively from hospital records to serve as controls (group B). Groups were matched with respect to age, body weight, body surface area, sex, cardiac rhythm, functional status, type of mitral valve pathology and associated lesions. RESULTS: Operative mortality was similar in both groups, but fewer postoperative complications occurred in group A. Total hospital stay, intensive care unit stay, postoperative bleeding, inotrope requirement and ventilatory support postoperatively was significantly less in group A. CONCLUSIONS: Right anterolateral thoracotomy provides excellent exposure of the mitral valve, even with a small left atrium, and offers a better cosmetic lateral scar which is less prone to keloid formation. In addition, right anterolateral thoracotomy is as safe as median sternotomy for primary mitral valve repair/replacement, and should be used as an initial approach to mitral valve surgery, while median sternotomy be kept for repeat mitral valve or other open-heart surgery required later in life.

Adult↗

PubMed1998

[Postoperative uptake of Ga-67 in planar scintigraphy and SPECT after median sternotomy].

Surgical alterations after median sternotomy can difficult the interpretation of scintigraphic images with Ga67. To analize the use of Ga67 scintigraphy in this patology, we wanted to know the Ga67 distribution in patients who had suffered median sternotomy. We studied 8 patients in the first month after median sternotomy without infection complication and performed planar images and SPECT. Ga67 showed uptake in liver, spleen and bone. Sternal uptake was greater or lesser than liver uptake but always showed an homogeneous distribution. No mediastinum uptake was observed. Surgical wound showed Ga67 uptake during the first week after sternotomy. To know the < > distribution of Ga67 in patients after median sternotomy allows the scan interpretation when we suspect infectous complications.

Bone and Bones↗

PubMed1998

Effect of sternotomy direction on the incidence of inadvertent pleurotomy.

OBJECTIVE: Median sternotomy was performed by 2 different techniques in order to determine whether there was a difference in the incidence of inadvertent pleural entry. EXPERIMENTAL DESIGN: Patients were prospectively evaluated and reviewed at a mean follow-up interval of 8.2 months. PATIENTS AND METHODS: Ninety five consecutive patients underwent primary sternotomy at a single tertiary referral center. MEASURES: Planned outcome measures included, incidence of pleural entry, length of hospitalization, and chest tube site related postoperative morbidity. RESULTS: Group 1 (n=49) had sternotomy undertaken from the sternal notch proceeding downwards. Group 2 (n=46) underwent sternotomy performed from the xiphoid upwards. Mediastinal evaluation revealed a significant reduction in the incidence of pleural violation for group 1 (3) versus group 2 (11) (p=0.014). This difference was not found to be surgeon specific. CONCLUSIONS: Sternotomy undertaken from the sternal notch proceeding downwards is shown to be associated with a reduced incidence of inadvertent pleural entry. Potential advantages for this approach also include reduced respiratory morbidity, less chest tube site complications and a trend to reduced length of hospitalization.

Adult↗

PubMed2002

Biomechanical porcine model of median sternotomy closure.

BACKGROUND: Healing complications following median sternotomy commonly include instability, nonunion, and infection. They are associated with a high mortality rate if mediastinitis supervenes. Closure complications are best avoided by improving stability at the union, but there has thus far been no widespread agreement among surgeons about relative superiority among the available closure techniques. MATERIALS AND METHODS: A biological sternotomy closure model was developed utilizing whole porcine sterna. A special stainless-steel clamp with multiple spikes was created to reliably attach the sterna to a biomechanical testing device. RESULTS: Two wiring techniques, single peristernal and pericostal figure-eight, were used in 14 fresh cadaveric porcine sterna. The more rigid closure utilized single peristernal wires (P < 0.0001). There was no tissue associated with clamp spikes penetrating the specimen's layers, and there was no clamp displacement even at closure failure loads. CONCLUSIONS: The porcine sternotomy model is a valuable tool for comparing closure techniques based on geometrical and mechanical wiring patterns. The model's low cost and easy reproducibility make it a promising first step in sternotomy closure research. The stainless-steel clamp used in the porcine model provided reliable repeat specimen fixation.

Animals↗

PubMed2002

[Coronary bypass operation with complete median sternotomy in awake patients with high thoracic peridural anesthesia].

OBJECTIVE: High thoracic epidural anesthesia (TEA) combined with general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques have rendered the use of TEA alone in conscious patients possible and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization the heart is usually approached via median sternotomy, therefore the use of TEA alone was applied in awake patients with multi-vessel coronary artery disease who underwent CABG via median sternotomy. METHODS: A total of 10 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at T1/2 or T2/3. Total arterial myocardial revascularization was performed after median sternotomy. In addition to standard monitoring, anesthetic sensory and motor block levels were determined using an epidural scoring scale for arm movements (ESSAM). RESULTS: Except for one patient who required intraoperative endotracheal intubation due to a pneumothorax, all patients were awake and maintained spontaneous breathing during the entire procedure. Compared to baseline values, hemodynamic parameters, e.g. arterial blood pressure (SAP, MAP, DAP) and heart rate significantly declined during coronary anastomosis. No significant hypercarbia was observed. The intraoperative pain level was subjectively estimated by the patients as less than 20 out of 100 (median 10.95% confidence interval 4.2-21.6) using a visual analogue scale. All patients rated TEA as "good" or "excellent." Adverse effects associated with TEA were not observed. CONCLUSIONS: We could demonstrate that the use of TEA alone for CABG via median sternotomy was feasible and produced good results. High patient satisfaction in our small and highly selected cohort could be reported. Nevertheless, randomized controlled trials in large cohorts are mandatory to definitively evaluate the role of TEA alone in cardiac surgery.

Aged↗

PubMed2003

Coronary artery bypass grafting via sternotomy in conscious patients.

The application of high thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques rendered the sole use of TEA in conscious patients possible, and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization, the heart is usually approached via sternotomy; therefore, the sole use of TEA was applied in awake patients who underwent CABG via sternotomy. A total of 7 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at the levels of T1-2 or T2-3, respectively. Total arterial myocardial revascularization was performed after partial lower sternotomy. Besides standard monitoring, anesthetic levels were determined using an epidural scoring scale for arm movements (ESSAM). While 6 patients were awake and spontaneously breathing during the entire procedure, one patient had to be intubated intraoperatively because of respiratory distress caused by phrenic nerve palsy. Hemodynamics were stable throughout the operation. No significant arterial hypercarbia occurred. All patients rated TEA as "good" or "excellent." We could demonstrate that the single use of TEA for CABG via sternotomy was feasible and that the patients felt well, were painfree, and remained hemodynamically stable. High patient satisfaction in our small and highly selected cohort can be reported. Because beating heart surgery in a conscious patient still carries a significant risk, further randomized controlled trials are mandatory to definitively evaluate the role of sole TEA in cardiac surgery.

Aged↗

PubMed2000

Is median sternotomy invasive? A comparison between minimally invasive direct coronary artery bypass and off-pump bypass.

Although minimally invasive direct coronary artery bypass (MIDCAB) eliminates the need for median sternotomy and cardiopulmonary bypass, its indications are limited. Conversely, coronary artery bypass without cardiopulmonary bypass (off-pump bypass) enables complete surgical revascularization under an optimal surgical field established by median sternotomy, even if patients have multivessel disease. The present study was designed to determine the invasiveness of median sternotomy by comparing 11 patients who underwent MIDCAB and 5 who underwent off-pump bypass between May 1997 and April 1998. There were no significant differences between the MIDCAB group and the off-pump group in age, being 57 +/- 11 vs 66 +/- 8 years old, the operative time, being 321 +/- 149 vs 441 +/- 205 min, the number of grafts, being 1.0 vs 1.4/patient, peak creatine kinase (CK) values, being 662 +/- 436 vs 609 +/- 56 IU/l, the peak CK-muscle-brain values, being 12 +/- 9 vs 16 +/- 5 IU/l, and the postoperative blood loss, being 369 +/- 198 vs 541 +/- 204 ml. Although there was no significant difference in peak C-reactive protein, at 17 +/- 5 vs 20 +/- 2 mg/dl, the periods declining within the normal ranges were shorter in the MIDCAB group than in the off-pump group, at 7 +/- 1 vs 15 +/- 2 days (P > 0.01). The hospital stay was almost the same in both groups, at 16 +/- 8 vs 26 +/- 14 days. These findings suggest that off-pump bypass is more invasive than MIDCAB, which may be attributed to the median sternotomy.

Aged↗

PubMed2006

Midterm results for endovascular stent grafts via median sternotomy for distal aortic arch aneurysm.

Dislocation or perigraft leakage is a major problem during the follow-up period for endovascular stent graft (EVG) implantation via median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied for the prevention of these complications. Here, we evaluate the midterm results and the efficacy of anchoring sutures. There were 21 male and 2 female patients enrolled in the study with an average age of 70 years (59-83). Aneurysm types were 21 true aneurysms (13 fusiform, 8 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. Total arch replacement was performed in two patients and aortocoronary bypass grafting was combined in four patients. Anchoring sutures to fix the EVG via median sternotomy were applied for 11 recent patients. The average follow-up period was 44 (22-79) months. There were no operative mortalities, but one case of paraplegia, one of stroke, and two of temporary spinal cord dysfunction. Complications related to EVG via median sternotomy occurred in five patients who had not received anchoring sutures, but the 11 patients with anchoring sutures showed no EVG-related complications. A chronic type B dissection revealed impending rupture due to false lumen infection 1 year after operation and repeat surgery was performed. Stent dislocation occurred in four patients, two of whom required repeat surgery via left thoracotomy due to endoleakage 3 and 4 years after surgery. One died from aneurismal rupture 5 years after surgery. One required emergency graft replacement because of graft perforation 5 years after surgery. The proportion of patients free from EVG-related events at 5 years after surgery was 75%. Anchoring sutures (P = 0.0155) and a large aneurysm of more than 80 mm (P = 0.0190) were predictors of late EVG-related complications. There were five late deaths: two were from stroke, one from rupture, one from cancer, and one from multiple organ failure after repeat surgery. EVG shortens postoperative recovery with relatively lower mortality, but spinal cord injury is a complication occurring with a relatively high rate. Patients with large aneurysms are not good candidates for EVG implantation via median sternotomy Anchoring sutures to fix the EVG to the aortic wall should help prevent EVG-related events and improve the durability of EVG.

Aged↗

PubMed2004

Manubriotomy versus median sternotomy in thymectomy for myasthenia gravis. Evaluation of the pulmonary status.

OBJECTIVE: In a prospective study, the effect of thymectomy on the pulmonary status of 50 consecutive patients with myasthenia gravis was evaluated over a time range of 4 years in the Chest and Chest surgery departments in the Cairo University Clinics and Thoracic Surgery Department of the Evangelisches Krankenhaus Duisburg-Nord. METHODS: The patients were divided into two groups: Group I included 26 patients who underwent thymectomy through median sternotomy. The mean age of the patients in this group was 24.8+/-10.5 (5-41) years. They were 19 females and seven males. Thirteen of the patients were in Myasthenia Gravis Foundation of America (MGFA) class IIa, and 12 were in class IIb, and one was in class IIIa. Group II included 24 patients who underwent thymectomy through manubriotomy. The mean age of the patients in this group was 25.2+/-9.2 (12-41) years. They were 13 females and 11 males. Eight of the patients were in MGFA class 2a, 14 were in class IIb, and two were in class IIIa. RESULTS: When compared to group I in which postoperative ventilation was required in 15.4% of patients, postoperative ventilation was not necessary in patients of group II with a statistically significant difference (P=0.04). The mean duration of stay in the intensive care unit was 111.4h in group II, and 169.7h in group I (P=0.03). The peak inspiratory flow rate and the forced vital capacity were also statistically significantly better in group II. There was no mortality in both groups, and the morbidity was higher in the median sternotomy group. CONCLUSION: Thymectomy through a manubriotomy, which allows extensive removal of ectopic thymic tissue in addition to the thymus through a less invasive approach than a full median sternotomy, is associated with a significantly smoother postoperative course and less pulmonary complications, when compared with thymectomy through a full median sternotomy.

Adolescent↗

PubMed2006

Initial experience with non-thoracic, extraperitoneal, off-pump insertion of the Jarvik 2000 Heart in patients with previous median sternotomy.

BACKGROUND: Successful implantation of left ventricular assist devices (LVADs) in patients with previous median sternotomy remains challenging. METHODS: Seven patients underwent implantation of a Jarvik 2000 Heart by an extrathoracic, extraperitoneal, sub-costal surgical approach, which allows easy exposure of the diaphragmatic surface of the heart and the supraceliac aorta. All patients were at very high risk and were receiving high doses of inotropic agents to maintain their cardiac function. All had undergone prior median sternotomy. We compared data for blood loss and intensive care unit (ICU) stay with those of 15 patients in whom the HeartMate I vented electric LVAD was placed through a re-do sternotomy incision. RESULTS: All 7 patients survived the surgical procedure for implantation of the Jarvik 2000. All 7 patients were rapidly rehabilitated and had a short stay in the ICU (mean 3.3 days, range 1 to 8 days), as compared with the re-do HeartMate patients (mean 10.3 days, range 3 to 33 days) (p = 0.005). The average 12-hour blood loss was 635 ml in the Jarvik patients compared with 2,405 ml in the re-do HeartMate patients (p = 0.028). The cardiac index improved significantly in all Jarvik patients. CONCLUSIONS: The extrathoracic, extraperitoneal, sub-costal surgical approach is less invasive than a median sternotomy and allows the Jarvik 2000 to be implanted quickly and without cardiopulmonary bypass (CPB). By avoiding CPB and an extensive mediastinal dissection, bleeding is decreased in these hypocoagulable patients with compromised end-organ function. The decreased operative morbidity and mortality associated with this technique may allow consideration of the Jarvik 2000 Heart for safe and effective implantation in home-bound New York Heart Association (NYHA) Class III and IV patients.

Blood Loss, Surgical↗

PubMed2000

Early outcome and graft patency in mammary artery grafting of left anterior descending artery with sternotomy or anterior minithoracotomy.

BACKGROUND: The main objective of this study was to retrospectively compare early outcome and graft patency in patients who underwent coronary artery bypass grafting with the internal thoracic artery to the left anterior descending artery via an anterior minithoracotomy or median sternotomy and without the use of extracorporeal circulation. METHODS: One hundred thirty consecutive patients were studied. Median sternotomy was performed in 77 patients and anterior minithoracotomy in 53 patients. RESULTS: There were no differences in early clinical data or persistent postoperative pain between the groups. Early graft patency was 88% in the thoracotomy group and 96% in the sternotomy group (p = 0.3). Five of 7 patients who presented with a significant stenosis at the first coronary angiography had a normal angiogram at the reangiography. None of the patients with nonsignificant stenosis at the early coronary angiography had any clinical signs of ischemia or chest pain. CONCLUSIONS: In our experience, anterior minithoracotomy and median sternotomy are different and distinguishable regarding early outcome and early graft patency. Most of the stenoses visualized at the early coronary angiography had vanished at a later coronary angiography, which makes the interpretation of the angiogram hazardous as a tool for the decision for redo procedure in the early postoperative period.

Adult↗

PubMed2001

Minimal sternotomy approach for congenital heart operations.

BACKGROUND: In recent years, minimal access cardiac operations have increased in application in both the adult and pediatric population. As our experience has grown with these approaches to atrial septal defect closure, we have expanded the same approach to the repair of more complex congenital heart disease. METHODS: At the Children's Hospital in Boston, from August 1996 to November 1999, a minimal sternotomy approach was used to surgically correct 104 children with congenital heart defects other than atrial septal defect. The approach, in most patients, consisted of a skin incision based over the xiphisternum, 3.5 to 5 cm in length, with division of the xiphoid only and elevation of the sternum by fixed retractor. All patients underwent cannulation for cardiopulmonary bypass through the great vessels in the chest using this same incision. The lesions corrected included ventricular septal defect in 41 patients, tetralogy of Fallot in 27, common atrioventricular canal in 15, mitral valve operation in 3.5, and other defects in 18 patients. There were 53 male and 51 female patients. Mean age at operation was 1.4 years (range, 2 weeks to 11 years). RESULTS: There were no deaths. The mean cardiopulmonary bypass time was 71 minutes (standard deviation, 19 minutes), mean cross-clamp times 40.8 minutes (standard deviation, 13 minutes), and length of stay 4.5 days (standard deviation, 1.9 days). Complications included transient atrioventricular block in 2 patients, pleural effusion requiring drainage in 4, and pericardial effusion in 3 patients. When compared to similar lesions repaired using a full sternotomy approach there was no difference in operating times and length of stay tended to be shorter in the minimal sternotomy group. CONCLUSIONS: A minimal sternotomy approach can be used to repair congenital cardiac lesions other than atrial septal defects. It gives good exposure, particularly for transatrial repairs, does not prolong ischemic times, and may lead to shorter hospital stay.

Child↗

PubMed2003

Median sternotomy for pneumonectomy in patients with pulmonary complications of tuberculosis.

BACKGROUND: Traditionally, a thoractomy incision is used for pulmonary complications of tuberculosis. An attractive alternative is being presented by the use of midline sternotomy in such patients, which is the aim of this study. METHODS: Five patients (four male, one female) with pulmonary complications of tuberculosis requiring surgical therapy in 1993 and 1994 were treated through a median sternotomy. The median patient age at time of surgery was 40.2 years and the median patient follow-up was 4.0 years (range 1.0 to 5.0 years) in this retrospective review. RESULTS: All patients had uncomplicated operative courses and were discharged from the hospital. One patient's in-hospital postoperative course was complicated by prolonged ventilator dependency requiring temporary tracheostomy; he died 1 year postoperatively after hospital discharge due to recurrent multidrug-resistant tuberculosis. Sternal wound infections and bronchopleural fistulas were not observed in any patients. CONCLUSIONS: Surgical treatment of pulmonary complications of tuberculosis was traditionally performed through a thoracotomy approach. Many patients with tuberculous lungs have pulmonary adhesions or intrathoracic scarring from previous surgery, which would require extrapleural resection. Bleeding was a frequent complication of this procedure. Sternotomy offers excellent exposure of the intrapericardial vessels, and reduced postoperative disability compared to the standard thoracotomy, which may be an advantage given that the majority of patients in this population have poor pulmonary function. We recommend median sternotomy as an alternative operative approach in selected patients with pulmonary complications of tuberculosis.

Adult↗