Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Pa...Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.展开更多
Background: The use of a vascularized pedicle flap of diaphragmatic muscle (DF) for reconstructive procedures in the chest has many advantages. Yet, despite the excellent reported results, the use of DF has not been w...Background: The use of a vascularized pedicle flap of diaphragmatic muscle (DF) for reconstructive procedures in the chest has many advantages. Yet, despite the excellent reported results, the use of DF has not been widespread. Some factors for the less widespread use of DF have been, concern about diaphragmatic function, hesitation to use such a vital muscle for reconstructive purposes, and most importantly, the technical aspects for the preparation of the flap. Methods: Using a cadaveric model, the vascular anatomy of the diaphragm and the steps for the preparation of the DF was defined and illustrated for both the right and left hemidiaphragm. Results: No perioperative mortality with the use of DF has been recorded. Function of the native diaphragm has not been impaired. Bronchopleural fistulas and pericardial defects have healed in all instances. Excellent repair has been achieved in all patients with esophageal lesions. The disruption of the repaired native diaphragm and visceral herniation has been reported but it has been attributed to the learning curve and the technique of repair. Conclusion: With a better understanding of the vascular anatomy of the diaphragm and a formal methodical approach to harvesting the DF, more surgeons will be encouraged to use DF with excellent results.展开更多
文摘Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.
文摘Background: The use of a vascularized pedicle flap of diaphragmatic muscle (DF) for reconstructive procedures in the chest has many advantages. Yet, despite the excellent reported results, the use of DF has not been widespread. Some factors for the less widespread use of DF have been, concern about diaphragmatic function, hesitation to use such a vital muscle for reconstructive purposes, and most importantly, the technical aspects for the preparation of the flap. Methods: Using a cadaveric model, the vascular anatomy of the diaphragm and the steps for the preparation of the DF was defined and illustrated for both the right and left hemidiaphragm. Results: No perioperative mortality with the use of DF has been recorded. Function of the native diaphragm has not been impaired. Bronchopleural fistulas and pericardial defects have healed in all instances. Excellent repair has been achieved in all patients with esophageal lesions. The disruption of the repaired native diaphragm and visceral herniation has been reported but it has been attributed to the learning curve and the technique of repair. Conclusion: With a better understanding of the vascular anatomy of the diaphragm and a formal methodical approach to harvesting the DF, more surgeons will be encouraged to use DF with excellent results.
