Journal of Indonesia Vascular Access

Sternal resection and reconstruction due to sternal destruction caused by malignancy: a case report

Giadefa Imam Cesyo, I Wayan Sudarma — Mon, 10 Mar 2025 00:00:00 +0000

Introduction: Sternal resection and reconstruction are uncommon chest wall procedures but can pose significant challenges in their management. Sternal resection may lead to thoracic cavity instability, making careful patient selection followed by an appropriate reconstruction technique.

Case: We report a case of sternal resection and reconstruction using reconstruction plates and hernia mesh. A 21-year-old male presented with a rapidly growing anterior chest wall mass, increasing in size over three months prior to surgery. The mass measured 15 x 10 x 8 cm, was firm, and fixed. A CT scan revealed an irregular solid mass originating from the sternum, with destruction of the sternal bone. A procedure was performed involving the resection of anterior chest wall and reconstruction using reconstruction plates and hernial mesh. The resection of large portions of the chest wall poses complex challenges due to technical difficulties, surgical complications, and respiratory failure caused by chest wall instability and paradoxical movements. Four types of sternal defects are generally defined: partial longitudinal sternectomy > 75% of the sternal width, subtotal lower, subtotal upper, and subtotal mid sternectomy. Full reconstruction is generally indicated for resections involving the entire width of the sternum. Various techniques have been proposed, including myocutaneous flaps, the use of mesh and patches supplemented with methacrylate composites, titanium mesh, autograft or allograft bone, and prosthetics. However, no standardized technique exists. The choice of technique is largely based on the surgeon’s experience. This report describes a relatively simple technique using readily available and economical prostheses to achieve a functionally stable chest wall. In this case, total mid-sternectomy was performed, followed by reconstruction using two reconstruction plates placed transversely on the second and third ribs, with hernia mesh beneath. The patient was extubated 24 hours postoperatively, although minimal paradoxical movements were observed without accompanying respiratory difficulty.

Conclusion: Reconstruction plates and hernia mesh can maintain respiratory mechanics but require refinement to improve chest wall stability and protective function against external trauma.

Mini-Bentall procedure for severe aortic regurgitation and root dilation: a case report of rapid recovery, and excellent outcomes

I Komang Adhi Parama Harta, I Putu Sakamekya Wicakasana Sujaya — Tue, 11 Mar 2025 00:00:00 +0000

Introduction: The Bentall procedure has long been regarded as the gold standard for addressing combined aortic valve and root pathologies. With advancements in minimally invasive cardiac surgery, the mini-Bentall procedure has emerged as a promising alternative to the traditional approach, offering reduced surgical trauma, shorter hospital stays, and improved postoperative recovery.

Case illustration: This report presents the case of a 66-year-old male with severe aortic regurgitation and aortic root dilatation who underwent a successful mini-Bentall procedure. Preoperative evaluation revealed significant left ventricular dysfunction with an ejection fraction of 30.8%, severe aortic regurgitation, and dilatation of the aortic root. The surgery was performed via a mini-sternotomy approach, with careful resection of the aortic root and valve and replacement with a composite graft. Postoperative recovery was uneventful, with minimal bleeding, no mechanical ventilation required, and a significantly reduced length of hospital stay.

Conclusion: This case highlights the feasibility and benefits of the mini-Bentall procedure as a less invasive yet effective approach to complex aortic surgery, demonstrating excellent outcomes and rapid recovery.

Successful percutaneous mechanical thrombectomy treatment for a patient with chronic deep vein thrombosis: a case report

Maranatha Maranatha, Ketut Putu Yasa — Thu, 13 Mar 2025 00:00:00 +0000

Background: This case report details the management of atypical chronic deep vein thrombosis (DVT) in a 24-year-old male. The treatment of DVT is complex and case-dependent; however, most individuals are managed with oral anticoagulation therapy, while complex cases can be treated with advanced interventions. Only a few publications discuss about endovascular procedure of chronic DVT. This report discusses a singular case of an atypical or complex DVT undergoing a thrombectomy using an Indigo Penumbra system.

Case illustration: A 24-year-old male was admitted to the hospital with bilateral leg swollen for 8 years ago. His history was unremarkable, and he was diagnosed with bilateral lower extremities deep vein thrombosis and was routinely administered anticoagulants. Laboratory results showed a significant increase in d-dimer levels. Venography confirmed bilateral deep vein thrombosis in the femoral vein system. He then underwent percutaneous mechanical thrombectomy with the Indigo Penumbra system. Small fragments of white thrombus were collected from the system container. He was discharged 1 day post-operatively and scheduled for further workup.

Conclusion: This case report elaborates on a patient with an atypical chronic white thrombus DVT who underwent a thrombectomy after imaging showed extensive thrombotic disease in the right lower extremity. Despite the few publications, percutaneous mechanical thrombectomy using the Indigo Penumbra System showed promising results in chronic DVT.

Role of awake thoracoscopy in diagnosis before chest tube insertion in lung empyema

Thu, 03 Apr 2025 00:00:00 +0000

Background: Awake thoracoscopy diagnostic (ATD) is a valuable procedure performed before the insertion of a chest tube to visually identify lung and pleural diseases. This technique, which utilises thoracic spinal anaesthesia, allows patients to remain conscious during the procedure and eliminates the need for intensive care unit (ICU) admission post-operation. The purpose of this study is to demonstrate ATD's effectiveness in early identification and management of complex pleural infections, particularly in high-risk and resource-constrained settings

Case Report: This case report describes a 56-year-old male who presented to the Emergency Department of RSUP Sitanala Tangerang with worsening intermittent dyspnea over three days, accompanied by low-grade fever, decreased appetite, weight loss, and a persistent cough. Diagnostic imaging revealed significant loculated pleural effusion, and thoracentesis yielded only 10 cc of purulent fluid, indicating a possible infectious process. A thoracic surgeon recommended awake thoracoscopy under thoracic spinal anaesthesia for direct evaluation and management. Intraoperative findings included thick pleural peel, necessitating thorough irrigation of the pleural cavity. A water-seal drainage (WSD) system was established for ongoing fluid management.

Conclusion: Awake thoracoscopy diagnostic demonstrates significant advantages in the preoperative evaluation of patients with pleural diseases, particularly in cases involving active tuberculosis. Its minimally invasive nature and the benefits of awake procedures underscore its potential as a preferred diagnostic approach in thoracic surgery.

Comparing Short Outcomes of Robotic-Assisted vs. Video-Assisted Thoracoscopic Surgery for Lobectomy in Non-Small Cell Lung Cancer in Asia: A Systematic Review and Meta-Analysis

I Made Sathya Vijayananda, Putu Raka Widhiarta, I Wayan Sudarma — Wed, 05 Mar 2025 00:00:00 +0000

Background: Open surgery remains a therapeutic option for early-stage non-small cell lung cancer (NSCLC), though it is commonly associated with higher complication rates and prolonged hospitalization. Minimally invasive techniques such as robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) have emerged as widely accepted alternatives for lobectomy. However, comparative analysis is needed to evaluate their relative clinical effectiveness.

Methods: This systematic review and meta-analysis included studies published between January 2014 and September 2024, retrieved from PubMed, ScienceDirect, and Cochrane databases. A total of 927 records were screened, and five studies met the inclusion criteria, focusing on short-term outcomes of RATS versus VATS for lobectomy in NSCLC patients across Asia. Study quality was assessed using the Cochrane Risk of Bias 2.0 tool, and all procedures followed PRISMA and Cochrane Handbook guidelines. Statistical analysis was performed using Review Manager (RevMan) version 5.4.1.

Results: Five studies comprising 1,091 patients (404 RATS; 687 VATS) were included. RATS showed a shorter hospital stay (SMD = -0.53; 95% CI: -0.93 to -0.14; I² = 88%; p = 0.008) and chest tube duration (SMD = -0.35; 95% CI: -0.65 to -0.04; I² = 80%; p = 0.03). No significant differences were observed in operative time or number of dissected lymph nodes.

Conclusion: RATS may offer clinical benefits in reducing hospitalization and chest tube duration, while maintaining comparable outcomes to VATS in operative time and lymphadenectomy.

The effect of co-induction of fentanyl compared to oxycodone on anesthetic depth and hemodynamic status in surgical patients under general anesthesia at Prof. Ngoerah Denpasar General Hospital

Aninda Tanggono — Tue, 10 Jun 2025 00:00:00 +0000

Introduction: Laryngoscopy and endotracheal intubation during general anesthesia can elicit sympathetic responses, including elevated blood pressure and heart rate. Fentanyl and oxycodone are opioids used for anesthesia co-induction to attenuate this response. This study aims to compare the co-induction effects of fentanyl and oxycodone on anesthesia depth and hemodynamic stability.

Methods: This was a prospective observational study involving 40 adult patients with ASA I–II status undergoing general anesthesia at RSUP Prof. Ngoerah Denpasar. Subjects were randomized into two groups: fentanyl 2 µg/kg BW and oxycodone 0.2 mg/kg BW. All patients underwent standard induction protocols. The depth of anesthesia was assessed using the CONOX monitor (qCON), while hemodynamic status was evaluated through blood pressure, heart rate, and stroke volume via USCOM. Data were analyzed using t-tests and Mann-Whitney U tests with significance set at p<0.05.

Results: There were no statistically significant differences in mean arterial pressure or heart rate between the groups (p>0.05), indicating similar hemodynamic responses. However, stroke volume reduction after intubation was significantly less in the oxycodone group (median ΔSV 3 vs 11.5; p<0.001). Additionally, qCON values showed better anesthesia depth with oxycodone (51.0 ± 5.8 vs 60.5 ± 7.5; p<0.001).

Conclusion: Oxycodone co-induction results in better anesthesia depth and equal or superior hemodynamic stability compared to fentanyl. Oxycodone may be considered an effective alternative for co-induction in general anesthesia.