David Sadhu

Surgical management of thoracic outlet syndrome: a 10-year experience

Background:  Thoracic Outlet Syndrome (TOS) refers to compression of the neurovascular structures in the region between the scalene muscles and the first rib, or by anatomical abnormalities such as cervical rib, fibrous bands and other variations in the scalene musculature.

A 7-year Experience with Thoracoscopic Sympathectomy for Critical Upper Limb Ischemia

Severely symptomatic arterial insufficiency of an upper limb not suitable for revascularization is a difficult condition to manage. Thoracoscopic sympathectomy (TS) can be an effective procedure in this setting. Our experience with 18 consecutive thoracoscopic sympathectomy (TS) procedures over a period of 7 years has been reviewed. Indications, operative technique, complications, and outcome of surgery are analyzed. We performed 18 TS procedures on 17 patients during this period. There were no deaths. One patient had intraoperative hemorrhage necessitating conversion to open thoracotomy. Mean postoperative hospital stay was 2.3 days. Follow-up ranged from 6 to 72 months. All patients demonstrated clinical benefit from the procedure. Thoracoscopic sympathectomy is a useful option in patients with severely symptomatic hand and digital ischemia from occlusive small arterial disease like thromboangitis obliterans.

Doppler Adson’s Test: Predictor of Outcome of Surgery in Non-Specific Thoracic Outlet Syndrome

IntroductionOutcome of surgery in non-specific thoracic outlet syndrome (TOS) is variable. Duplex imaging of the subclavian artery during Adson’s maneuvre may help predict outcome.Patients and methodsA retrospective study of 16 cases of non-specific TOS who had pre-operative duplex imaging of the subclavian artery during Adson’s maneuvre was done and their outcomes following surgical decompression of the thoracic outlet studied.ResultsOf the eight cases with a positive Adson’s test, seven (87.5%) had a complete response of symptoms following surgery while in the eight cases with a negative test, only four (50%) had a favorable response to surgery.ConclusionDuplex scanning of the thoracic outlet during Adson’s maneuvre may help predict outcome of thoracic outlet decompression surgery in cases of non-specific TOS.

Adjuvante dorsale Stabilisierung der thorakalen und lumbalen Wirbelsäule bei tuberkulöser Spondylitis

ZusammenfassungOperationszielDorsale Stabilisierung der Wirbelsäule zur Frühmobilisation, Verkürzung des Krankenhausaufenthalts und Aufrechterhaltung der vorgenommenen Korrektur nach vorangegangenen Débridement und ventraler Knochenblocktransplantation bei tuberkulöser Spondylitis.IndikationenTuberkulöse Spondylitis, die eine ventrale Drainage, ein Débridement und eine Dekompression sowie eine Wirbelkörperfusion erfordert.Größerer Knochenverlust eines Wirbelkörpers.Kyphose über 25°.Begleitende Zerstörung der hinteren Säule.KontraindikationenSchlechter Allgemeinzustand, der eine so belastende Operation verbietet.Superinfektion einer tuberkulösen Fistel am Rücken.OperationstechnikDer erste Schritt besteht aus dem ventralen Débridement und einer Knochentransplantation. Dorsale Stabilisierung, vorzugsweise während derselben Operationssitzung, in Höhe der thorakalen Wirbelsäule und bei allen Patienten mit Osteoporose. Ungeachtet der Höhe des Herdes wird eine Rahmenfixation über sublaminare Drahtschlingen nach Hartshill bevorzugt. In Höhe der lumbalen Wirbelsäule wird bei fehlender Osteoporose die Plattenosteosynthese nach Steffee unter Verwendung transpedikulärer Schrauben bevorzugt.ErgebnisseZwischen Juni 1993 und Dezember 1996 wurden 25 Patienten (neun Männer, 16 Frauen, Durchschnittsalter 38,5 Jahre) mit tuberkulöser Spondylitis operiert. Durchschnittliche Nachuntersuchungszeit 16,9 Monate. Präoperative neurologische Ausfälle bei 15 Patienten persistierten nur zweimal. Der durchschnittliche Korrekturverlust lag bei 6,5°. Die durchschnittliche Dauer bis zur Fusion betrug 6 Monate. Ein Materialversagen wurde nicht beobachtet. Bei einem Patienten kam es infolge einer Infektion zum Ausriss einer Schraube. Bei einem Patienten trat vorübergehend eine neurologische Störung auf.AbstractObjectivePosterior instrumentation and stabilization allowing early mobilization, shortened hospital stay and maintenance of correction after debridement and bone grafting for tuberculous spondylitis through an anterior approach.IndicationsTuberculous spondylitis requiring anterior drainage, debridement and decompression, as well as interbody fusion.Significant bone loss of vertebral body.Kyphosis > 25°.Concomitant posterior column disease.ContraindicationsPoor general health precluding such an extensive intervention.Superinfection of tuberculous sinus on the back.Surgical TechniqueThe first stage consists of anterior debridement and bone grafting. During the second stage, preferably performed at the same sitting, a posterior stabilization is done. At the level of the thoracic spine and for all patients with osteoporosis irrespective of the level, a sublaminar wiring (Hartshill) is performed. At the lumbar spine pedicular screw fixation and Steffee plating are done in the absence of osteoporosis.ResultsBetween June 1993 and December 1996 25 patients (nine men, 16 women, average age 38.5 years) with tuberculous spondylitis underwent this two-stage procedure. Average length of follow-up 16.9 months. A preoperative neurologic deficit seen in 15 patients persisted only in two. The overall loss of correction amounted to 6.5°. The average time to fusion was 6 months. No implant failures were recorded. A screw pull-out secondary to infection accompanied by loss of correction occurred in one patient. Another patient experienced a transient neurologic deficit.

Standardisation of Preoperative Marking of Incompetent Perforators and Saphenopopliteal Junction on Doppler with Evaluation of "T" Technique

To standardise the preoperative marking of incompetent perforators and saphenopopliteal junction on Doppler with evaluation of “T” technique. A prospective study including 54 consecutive patients (61 lower limbs) who underwent surgery for varicose veins in 2003 and 2004 were included for preoperative marking. “T” technique is a technique of Doppler marking of an incompetent perforator, long limb of the T representing the course of the superficial vein and the junction of the T representing the site of perforator entering the deep fascia. Surgical correlation was done. The overall surgical detection rate of incompetent perforators was 199 / 220(90.5%); detection of the saphenopopliteal junction was 100%. The “T” technique of Doppler marking was found to be easy to perform and aided intraoperative detection.

Risk Factors for Peripheral Arterial Disease in the Tropics and Its Comparison with the Western Population

Objective: To identify and compare the existence of similar and other risk factors in the perspective of an Indian population. Methods: It was designed as a case control study and was conducted in the Department of General and Vascular Surgery Unit 2 of Christian Medical College, Vellore, India between the periods July 2003 to June 2005. 100 patients with an ABPI＜0.9 and 100 controls were studied. Results: Peripheral arterial disease (PAD) was found to be commoner among males (87%). While atherosclerosis was the commonest aetiology (54%), the incidence of Thromboangiitis Obliterans was also not uncommon (38%). Smoking was the main risk factor in the Indian context (83%) as compared to hypercholesterolemia (60%) in the West. The patients with atherosclerotic PAD were middle-aged and had concomitant diabetes (50%) and hypertension (30%). Conclusions: Peripheral arterial disease occurs in a relatively younger age group in India as Compared to their Western counterparts. Thromboangiitis Obliterans was found to be a significant aetiology for arterial occlusive disease, with smoking as the primary risk factor followed by diabetes, hypertension and hypercholesterolemia.