Zeynep Bilgi

Risk of serious perioperative complications with removal of double bars following the Nuss procedure

Objectives The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur. Methods All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course. Results Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01). Conclusions Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.

Previously Complicated Nuss Procedure Does Not Preclude Blind Removal of the Bar.

BACKGROUND Nuss procedure has become the procedure of choice for well-selected patients with pectus excavatum. Perioperative complications may pose difficulty during the subsequent bar removal due to adhesions and tissue plane disruptions during the initial surgery and repair. This report describes bar removal experience in patients whose Nuss procedures were complicated by cardiac injury, pericardial breach, and lung parenchyma/diaphragm injury during the initial procedure. METHODS A total of 529 patients who underwent Nuss procedure between 2007 and 2014 were recorded in a prospective database. Twenty patients with complications (cardiac injury [n = 1], pericardial breach [n = 3], and lung parenchyma/diaphragm injury [n = 16]) were identified. All bars were removed via subcutaneous tissue dissection, without intrathoracic visualization. RESULTS Average duration of bars was 36 months (±16 months). All bar removal procedures were completed without any need for extra interventions with negligible blood loss. Eighteen patients were able to be discharged within 2 postoperative days. CONCLUSION Blind bar removal in patients with previously complicated Nuss procedure seems safe and no other interventions (videothoracoscopy, subxiphoid incision, etc.) during bar removal seem to be necessary.

Feasibility and Complications in Concomitant Lung Resection With Minimally Invasive Repair of Pectus Excavatum

Minimally invasive repair of pectus excavatum (MIRPE) is the procedure of choice in experienced centers and can be offered in combination with other thoracic procedures. Between 2001 and 2013, 3 cases involving MIRPE and lung surgery were done in our clinic. While postoperative course of 2 procedures (MIRPE and video-assisted thoracoscopic surgery [VATS] segmentectomy and MIRPE and VATS bullectomy) were uncomplicated, the MIRPE and VATS lung biopsy patient developed major complications arising from prolonged air leak and was ultimately managed with an Eloesser flap. In carefully selected cases, simultaneous lung surgery and MIRPE can be done safely but problems of lung reexpansion, long-term drainage, and infection should be kept in mind.

Safe vascular and bronchial division techniques for VATS uniportal lung resections

VATS anatomic lung resections are becoming the standard of care for lung cancer with a long record of safety, feasibility, oncological adequacy. Following the multi-port VATS, uniportal VATS resections are becoming popular. However, uniportal VATS approach has unique challenges concerning vascular anatomy, angle of traction, stapler insertion and safe division of vessels and bronchi. In this article we are presenting a systematic description of technique for safe vascular and bronchial division for VATS uniportal anatomic resections. All operations were performed through a 3–5 cm utility incision at 5th intercostal space, using thoracoscopic and open surgical tools and endoscopic harmonic scalpel. After preparation of a vessel for division, a vascular tape was placed around the vessel and appropriate retraction for safe stapler orientation and passage was provided through intrathoracic manipulation of the vascular tape using a systemic approach. Bronchus was divided with the principle of cartilage to membranous approximation. Safe vascular and bronchial division are the most critical points for VATS lobectomy/segmentectomy operations. Uniportal VATS approach imposes additional geometric challenges for stapler orientation and placement due to further restriction of access, equipment crowding and hilar anatomy. Our technique provides practical solutions for uniportal lung resection.

No Adverse Outcomes of Video-Assisted Thoracoscopic Surgery Resection of cT2 Non-Small Cell Lung Cancer during the Learning Curve Period

Background Video-assisted thoracoscopic surgery (VATS) anatomic lung resections are gradually becoming the standard surgical approach in early-stage non-small cell lung cancer (NSCLC). The technique is being applied in cases of larger tumors depending on the experience of the surgical team. The objective of this study was to compare early surgical and survival outcomes in patients undergoing anatomic pulmonary resections using VATS and thoracotomy techniques for clinical T2 NSCLC during the adaptation period of the surgical team to the VATS approach. Methods The data of all patients who underwent anatomic pulmonary resection for NSCLC using VATS and open techniques since April 2012 were recorded to create a prospective lung cancer database. Clinical T2 NSCLC patients who underwent VATS anatomic lung resection were identified and compared with cT2 patients who underwent open resection. Results Between April 2012 and August 2014, 269 anatomical resections for NSCLC were performed (80 VATS and 189 thoracotomy). Thirty-four VATS patients who had clinical T2 disease were identified and stage-matched to thoracotomy patients. The average tumor diameter was comparable (34.2±11.1×29.8±10.1 mm vs. 32.3±9.8×32.5±12.2 mm, p=0.4). Major complications were higher in the thoracotomy group (n=0 vs. n=5, p=0.053). There was no 30-day mortality, and the 2-year survival rate was 91% for VATS and 82% for thoracotomy patients (p=0.4). Conclusion VATS anatomic resections in clinical T2 NSCLC tumors are safe and have perioperative and pathologic outcomes similar to those of thoracotomy, while remaining within the learning curve.

Laparoscopic toupet fundoplication for gastroesophageal reflux disease due to postpneumonectomy syndrome

Postpneumonectomy syndrome is a rare condition caused by rotational displacement of mediastinum over time after pneumonectomy. Usually, dynamic airway obstruction is the predominant symptom. We report the case of a 40-year-old lady who underwent left pneumonectomy due to mucoepidermoid carcinoma 3 years ago and presented to our department with recalcitrant gastroesophageal reflux symptoms such as heartburn and odynophagia. She also had objective reflux findings in pH monitorization. Laparoscopic Toupet fundoplication was performed and resulted in symptomatic relief.

Video-assisted thoracoscopic removal of esophageal leiomyoma in a patient with aberrant right subclavian artery

Esophageal leiomyoma one of the most common esophageal tumors and frequently cause dysphagia, requiring surgical removal for symptom control. Aberrant right subclavian artery may also cause similar symptoms but its incidence is lower. We report a case who had dual pathologies as possible causes of dysphagia. A straightforward bi-portal video-assisted thoracoscopic removal of an esophageal leiomyoma was performed in a patient with an aberant right subclavian artery coursing posterosuperior to the leiomyoma.