- Email: [email protected]
Thoracoscopic Excision of Migrated Kirschner Wire to Right Pulmonary Hilum
Ann Thorac Surg 2015;100:1461–3
Comment Used as the conduit of choice in the 1950s and 1960s, colonic interposition has not been used with frequency since the 1980s due to the current surgeon preference of a gastric tube for esophageal reconstruction for malignant disease and the low incidence of benign disease that requires esophageal replacement [4]. Despite the rarity with which colonic interposition is used today for esophageal reconstruction, surgeons should still maintain a familiarity with the procedure as well as the complications that such patients may present with in both the short-term and long-term. The complication we have presented, colopericardial fistula after colonic interposition, is extremely rare, with only a few cases reported, mostly from the 1980s [5–7]. A late complication, such as in our patient, was probably a result of a new pathology in the conduit, such as an ulcer or inflammation (diverticulitis) affecting the conduit and eventually leading to a fistulous complication. The development of a colopericardial fistula has several possible causes, many of which have been discussed in the few prior reported cases. The most common pathology cited has been ulcer formation due to ongoing gastric reflux into the colonic graft, leading to fistulization to neighboring structures. In the past, authors have emphasized the colon’s relative resistance to gastric reflux [7, 8]. However, gastric reflux has been demonstrated to be a major postoperative issue in up to 10% of patients after colonic interposition, with ulceration developing near the gastrocolic anastomosis in about one-third of patients [8]. Other additional causes that have been proposed include bile reflux colitis and Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1461
colonic pathology, including diverticulitis or a colon cancer, causing erosion into adjacent structures. A common presentation of these ulcers consists of pain and bleeding; however, more extreme presentations, such as the development of colobronchial fistulas, coloventricular, or colopericardial fistulas, as did in our patient, can occur. However, such a complication is generally a catastrophic event for the patient, with septic pericarditis having a significant rate of associated morbidity and mortality. In previously reported cases of colopericardial fistula, most patients died of overwhelming sepsis, and those that survived did so with the resection of the perforated interposition with cervical esophagotomy, with elective restoration of esophageal continuity deferred to a later time. Only one primary repair of the fistula has been reported [7]. In our patient, we were able to safely and effectively perform a primary closure of the defect between the colon and the pericardium with an omental flap, resulting in a long-term good outcome. If sufficient healthy tissue remains after debridement, primary closure of the perforation defect with preservation of the esophageal conduit follows the current accepted practice of preservation of the esophagus after perforation.
References 1. Thomas P, Fuentes P, Giudicelli R, Reboud E. Colon interposition for esophageal replacement: current indications and long-term function. Ann Thorac Surg 1997;64:757–64. 2. Duranceau A, Liberman M, Martin J, Ferraro P. End-stage achalasia. Dis Esoph 2012;25:319–30. 3. Davis PA, Law S, Wong J. Colonic interposition after esophagectomy for cancer. Arch Surg 2003;138:303–8. 4. Maish MS, DeMeester SR. Indications and technique for colon and jejunal interpositions for esophageal disease. Surg Clin N Am 2005;85:505–14. 5. Wetstein L, Ergin MA, Griepp RB. Colo-pericardial fistula: complication of colonic interposition. Texas Heart Inst J 1982;9:373–6. 6. Malcolm JA. Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 1968;55: 763–72. 7. Massop DW, DeMeester TR. Colo-pericardial fistula: a complication of bile-reflux colitis following substernal colonic interposition. Gullet 1992;2:132–5. 8. Isolauri J, Markkula H. Recurrent ulceration and colopericardial fistula as late complications of colon interposition. Ann Thorac Surg 1987;44:84–5.
Thoracoscopic Excision of Migrated Kirschner Wire to Right Pulmonary Hilum Gildardo Cort es-Juli an, MD, Jos e M. Mier, MD, and Carlos Brise~ no, MD Minimally Invasive Thoracic Surgery Institute, Hospital Angeles Interlomas, Mexico City, Mexico
Kirschner wires are often used for the stabilization of complex fractures. Wire migration is a rare but still recognized complication of its use. A 56-year-old man suffered a clavicle fracture at age 26 that was stabilized 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.102
FEATURE ARTICLES
pericardium. The left hemidiaphragm was opened circumferentially to gain access to the abdominal cavity. A large defect was identified in the gastrocolic area of the upper abdomen, with the nasogastric tube visible through the defect. The gastrocolic area was mobilized away from the diaphragm, and the defect was closed primarily using 30 interrupted Vicryl (Ethicon, Somerville, NJ) sutures. A large omental pedicle was mobilized and interposed between the repair and diaphragm. The abdominal and pleural cavities were copiously irrigated with warm saline and antibiotic solution. A defunctioning gastrostomy and feeding jejunostomy were placed. One chest tube was placed in the posterior mediastinum, and the diaphragm and thoracotomy were closed after the lung was reinflated. Postoperatively, the patient did well at discharge, tolerating a mechanical soft diet and supplemental nutrition through the J tube. The diet was advanced during her postoperative visits, and subsequently, the J tube was removed. During her subsequent visit, she complained of dysphagia to solids, and an esophagram revealed a stricture at the cologastric anastomosis. She underwent balloon dilation under fluoroscopy, and this was repeated, subsequently maintaining good nutrition but limited to soft mechanical diet.
ET AL CASE REPORT CORTES-JULI AN THORACOSCOPIC EXCISION OF MIGRATED K-WIRE
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ET AL CASE REPORT CORTES-JULI AN THORACOSCOPIC EXCISION OF MIGRATED K-WIRE
with one Kirschner wire, and for 30 years he was asymptomatic. Recently, he presented with cough and right thoracic pain. Chest radiographs revealed migration of the Kirschner wire, and thoracoscopic visualization revealed that the Kirschner wire had penetrated the middle lobe parenchyma and was in close contact with the right auricle. This case study reports the successful thoracoscopic treatment of a rare complication of Kirschner wire migration. (Ann Thorac Surg 2015;100:1461–3) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
M
artin Kirschner developed the Kirschner wire (Kwire) at the beginning of the nineteenth century; now it is commonly used for stabilization of complex fractures. Migration is a rare but recognized complication of orthopedic wire insertion. The first case was reported in 1943 in a young naval officer after fixation of a dislocated acromioclavicular joint. Since then, approximately 70 cases have been reported in the literature [1]. Study approval and patient consent was obtained for this case report. Thirty years ago, a healthy 26-old-man suffered a traumatic left mid shaft clavicle fracture. At that time, the treatment was the intramedullary placement of a K-wire. The correct position of the wire was documented by a postoperative chest radiograph. After treatment, the patient continued with his normal activities, which included work in an office and moderate physical exercise. The patient presented a history of a constant nonproductive cough without hemoptysis accompanied by chest pain related to the respiratory cycle. The first physician to see the patient ordered a chest radiograph, which depicted the migration of the K-wire to the contralateral
Accepted for publication Dec 30, 2014. Address correspondence to Dr Cort es-Juli an, Surgery Department, National Institute of Respiratory Diseases, Calzada De Tlalpan 4502, Colonia Secci on XVI, Mexico D.F , 14080, Mexico; e-mail: gildardounam@hotmail. com.
Fig 1. Posteroanterior and lateral chest radiograph showing the localization and the superomedial to inferolateral orientation of the K-wire in the middle lobe in left and right panels.
Ann Thorac Surg 2015;100:1461–3
hemithorax in mediastinal position close to the right auricle (Fig 1). The approach was complemented with a computed tomographic scan that showed the K-wire in the right hilar position (Fig 2). The patient was taken immediately to the operating room. After selective left bronchial intubation, the patient was placed in the left lateral decubitus position. Two incisions were made, one of 1 cm in the seventh intercostal space at the intersection with the midaxillary line and another one of 3 cm in the fifth intercostal space at the anterior axillary line intersection. After lateral mobilization of the lung, it was evident that the K-wire had crossed the mediastinum and had been introduced into the medial segment of the middle lobe. With the aid of a ring clamp, the K-wire was extracted from the lung and pulled out through the 3-cm incision (Fig 3). Hemostasis and an air leak test were performed. A Silastic chest drain was connected to a digital pleural drainage system (ThopazMedela, Baar, Switzerland). There were no postoperative complications, the chest drain was withdrawn on day 4, and the patient was discharged 24 hours later.
Comment The consequences of K-wire migration reported in the literature have been diverse and in some cases unusual. For example, pericardial tamponade, tracheal perforation, pulmonary artery lodging, pelvic bone migration, and intraspinal accommodation of K-wires have been reported [1–8]. The successful removal of intrathoracic K-wires using different approaches has been reported [8]. Which one is preferred depends on the location of the K-wire and the clinical condition of the patient. In emergent situations, or when damage to the heart or intrapericardial vessels is suggested, median sternotomy could be the first choice [2–4]. The preferred approach in light of the clinical condition and the viability reported by others would be thoracoscopic approach, as in this case study [5]. The mechanism of this silent migration into the right pulmonary hilum is not entirely clear. Although it has been described as peripheral intravascular embolization to the heart, this seems improbable in this case. Theories
Ann Thorac Surg 2015;100:1463–5
CASE REPORT BEAN ET AL ARTERIOVENOUS FISTULA AFTER NUSS PROCEDURE
1463
Fig 2. Chest computed tomography, mediastinal window, threedimensional reconstruction. The arrows show the position in the middle mediastinum and the cephalocaudal orientation of the wire going inside the lung parenchyma in left and right panels.
that include respiratory excursion or gravitational forces may be more relevant to this clinical presentation. Likewise, the movement favored by physical exercise could be added to the hypothesis of migration in this case. Certainly under any mechanism, the K-wire is able to reach any imaginable site in the body [6, 7]. In view of the multiple reports across the literature of complications after the use of K-wire, it is necessary to take preventive measures [8]. Some physicians recommend bending one tip of the wire to prevent its movement. For some authors, close clinical and radiographic postoperative follow-up examinations are essential after insertion of orthopedic wires, which should be withdrawn once treatment has concluded [2]. In conclusion, this case adds to the evidence that emphasizes the risks of K-wire use. It also shows the feasibility of the thoracoscopic approach when the clinical condition of the patient is stable.
References 1. Abbas A, Richmond N, McCormack DJ, et al. A 27-year-old man presenting with acute chest pain and dyspnea. Chest 2009;135:1684–7. 2. Zhang W, Song F, Yang Y, Tang J. Asymptomatic intracardiac migration of a Kirschner wire from the right rib. Interact Cardiovasc Thorac Surg 2014;18:525–6. 3. Anic D, Brida V, Jelic I, Orlic D. The cardiac migration of a Kirschner wire. A case report. Tex Heart Inst J 1997;24:359–61. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
4. Tubbax H, Hendzel P, Sergeant P. Cardiac perforation after Kirschner wire migration. Acta Chir Belg 1989;89:309–11. 5. Bezer M, Aydin N, Erol B, Lac¸in T, G€ uven O. Unusual migration of K-wire following fixation of clavicle fracture: a case report. Ulus Travma Acil Cerrahi Derg 2009;15: 298–300. 6. Foster GT, Chetty KG, Mahutte K, Kim JB, Sasse SA. Hemoptysis due to migration of a fractured Kirschner wire. Chest 2001;119:1285–6. 7. Lorenz G, Steinau G, Schumpelick V. [Intra-abdominal migration of a Kirschner wire from the femoral neck.]. Chirurg 1993;64:973–4. 8. Park S-Y, Kang J-W, Yang DH, Lim T-H. Intracardiac migration of a Kirschner wire: case report and literature review. Int J Cardiovasc Imaging 2001;27(Suppl 1):85–8.
Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum Jonathan F. Bean, MD, David Wax, MD, and Marleta Reynolds, MD Division of Pediatric Surgery, Department of Surgery, and Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
We report a case of a 13-year-old female patient who underwent the Nuss procedure for surgical correction of pectus excavatum. As a result of the procedure, the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.067
FEATURE ARTICLES
Fig 3. Thoracoscopic view. The introduction of the wire tip (long arrow) into the pericardial fat over the auricle (arrowhead) is shown on the left. The lung (thin arrow) and superior vena cava are shown (star). The ring clamp pulling the wire in the cephalic direction (star) is shown on the right.
Comment Used as the conduit of choice in the 1950s and 1960s, colonic interposition has not been used with frequency since the 1980s due to the current surgeon preference of a gastric tube for esophageal reconstruction for malignant disease and the low incidence of benign disease that requires esophageal replacement [4]. Despite the rarity with which colonic interposition is used today for esophageal reconstruction, surgeons should still maintain a familiarity with the procedure as well as the complications that such patients may present with in both the short-term and long-term. The complication we have presented, colopericardial fistula after colonic interposition, is extremely rare, with only a few cases reported, mostly from the 1980s [5–7]. A late complication, such as in our patient, was probably a result of a new pathology in the conduit, such as an ulcer or inflammation (diverticulitis) affecting the conduit and eventually leading to a fistulous complication. The development of a colopericardial fistula has several possible causes, many of which have been discussed in the few prior reported cases. The most common pathology cited has been ulcer formation due to ongoing gastric reflux into the colonic graft, leading to fistulization to neighboring structures. In the past, authors have emphasized the colon’s relative resistance to gastric reflux [7, 8]. However, gastric reflux has been demonstrated to be a major postoperative issue in up to 10% of patients after colonic interposition, with ulceration developing near the gastrocolic anastomosis in about one-third of patients [8]. Other additional causes that have been proposed include bile reflux colitis and Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1461
colonic pathology, including diverticulitis or a colon cancer, causing erosion into adjacent structures. A common presentation of these ulcers consists of pain and bleeding; however, more extreme presentations, such as the development of colobronchial fistulas, coloventricular, or colopericardial fistulas, as did in our patient, can occur. However, such a complication is generally a catastrophic event for the patient, with septic pericarditis having a significant rate of associated morbidity and mortality. In previously reported cases of colopericardial fistula, most patients died of overwhelming sepsis, and those that survived did so with the resection of the perforated interposition with cervical esophagotomy, with elective restoration of esophageal continuity deferred to a later time. Only one primary repair of the fistula has been reported [7]. In our patient, we were able to safely and effectively perform a primary closure of the defect between the colon and the pericardium with an omental flap, resulting in a long-term good outcome. If sufficient healthy tissue remains after debridement, primary closure of the perforation defect with preservation of the esophageal conduit follows the current accepted practice of preservation of the esophagus after perforation.
References 1. Thomas P, Fuentes P, Giudicelli R, Reboud E. Colon interposition for esophageal replacement: current indications and long-term function. Ann Thorac Surg 1997;64:757–64. 2. Duranceau A, Liberman M, Martin J, Ferraro P. End-stage achalasia. Dis Esoph 2012;25:319–30. 3. Davis PA, Law S, Wong J. Colonic interposition after esophagectomy for cancer. Arch Surg 2003;138:303–8. 4. Maish MS, DeMeester SR. Indications and technique for colon and jejunal interpositions for esophageal disease. Surg Clin N Am 2005;85:505–14. 5. Wetstein L, Ergin MA, Griepp RB. Colo-pericardial fistula: complication of colonic interposition. Texas Heart Inst J 1982;9:373–6. 6. Malcolm JA. Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 1968;55: 763–72. 7. Massop DW, DeMeester TR. Colo-pericardial fistula: a complication of bile-reflux colitis following substernal colonic interposition. Gullet 1992;2:132–5. 8. Isolauri J, Markkula H. Recurrent ulceration and colopericardial fistula as late complications of colon interposition. Ann Thorac Surg 1987;44:84–5.
Thoracoscopic Excision of Migrated Kirschner Wire to Right Pulmonary Hilum Gildardo Cort es-Juli an, MD, Jos e M. Mier, MD, and Carlos Brise~ no, MD Minimally Invasive Thoracic Surgery Institute, Hospital Angeles Interlomas, Mexico City, Mexico
Kirschner wires are often used for the stabilization of complex fractures. Wire migration is a rare but still recognized complication of its use. A 56-year-old man suffered a clavicle fracture at age 26 that was stabilized 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.102
FEATURE ARTICLES
pericardium. The left hemidiaphragm was opened circumferentially to gain access to the abdominal cavity. A large defect was identified in the gastrocolic area of the upper abdomen, with the nasogastric tube visible through the defect. The gastrocolic area was mobilized away from the diaphragm, and the defect was closed primarily using 30 interrupted Vicryl (Ethicon, Somerville, NJ) sutures. A large omental pedicle was mobilized and interposed between the repair and diaphragm. The abdominal and pleural cavities were copiously irrigated with warm saline and antibiotic solution. A defunctioning gastrostomy and feeding jejunostomy were placed. One chest tube was placed in the posterior mediastinum, and the diaphragm and thoracotomy were closed after the lung was reinflated. Postoperatively, the patient did well at discharge, tolerating a mechanical soft diet and supplemental nutrition through the J tube. The diet was advanced during her postoperative visits, and subsequently, the J tube was removed. During her subsequent visit, she complained of dysphagia to solids, and an esophagram revealed a stricture at the cologastric anastomosis. She underwent balloon dilation under fluoroscopy, and this was repeated, subsequently maintaining good nutrition but limited to soft mechanical diet.
ET AL CASE REPORT CORTES-JULI AN THORACOSCOPIC EXCISION OF MIGRATED K-WIRE
1462
ET AL CASE REPORT CORTES-JULI AN THORACOSCOPIC EXCISION OF MIGRATED K-WIRE
with one Kirschner wire, and for 30 years he was asymptomatic. Recently, he presented with cough and right thoracic pain. Chest radiographs revealed migration of the Kirschner wire, and thoracoscopic visualization revealed that the Kirschner wire had penetrated the middle lobe parenchyma and was in close contact with the right auricle. This case study reports the successful thoracoscopic treatment of a rare complication of Kirschner wire migration. (Ann Thorac Surg 2015;100:1461–3) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
M
artin Kirschner developed the Kirschner wire (Kwire) at the beginning of the nineteenth century; now it is commonly used for stabilization of complex fractures. Migration is a rare but recognized complication of orthopedic wire insertion. The first case was reported in 1943 in a young naval officer after fixation of a dislocated acromioclavicular joint. Since then, approximately 70 cases have been reported in the literature [1]. Study approval and patient consent was obtained for this case report. Thirty years ago, a healthy 26-old-man suffered a traumatic left mid shaft clavicle fracture. At that time, the treatment was the intramedullary placement of a K-wire. The correct position of the wire was documented by a postoperative chest radiograph. After treatment, the patient continued with his normal activities, which included work in an office and moderate physical exercise. The patient presented a history of a constant nonproductive cough without hemoptysis accompanied by chest pain related to the respiratory cycle. The first physician to see the patient ordered a chest radiograph, which depicted the migration of the K-wire to the contralateral
Accepted for publication Dec 30, 2014. Address correspondence to Dr Cort es-Juli an, Surgery Department, National Institute of Respiratory Diseases, Calzada De Tlalpan 4502, Colonia Secci on XVI, Mexico D.F , 14080, Mexico; e-mail: gildardounam@hotmail. com.
Fig 1. Posteroanterior and lateral chest radiograph showing the localization and the superomedial to inferolateral orientation of the K-wire in the middle lobe in left and right panels.
Ann Thorac Surg 2015;100:1461–3
hemithorax in mediastinal position close to the right auricle (Fig 1). The approach was complemented with a computed tomographic scan that showed the K-wire in the right hilar position (Fig 2). The patient was taken immediately to the operating room. After selective left bronchial intubation, the patient was placed in the left lateral decubitus position. Two incisions were made, one of 1 cm in the seventh intercostal space at the intersection with the midaxillary line and another one of 3 cm in the fifth intercostal space at the anterior axillary line intersection. After lateral mobilization of the lung, it was evident that the K-wire had crossed the mediastinum and had been introduced into the medial segment of the middle lobe. With the aid of a ring clamp, the K-wire was extracted from the lung and pulled out through the 3-cm incision (Fig 3). Hemostasis and an air leak test were performed. A Silastic chest drain was connected to a digital pleural drainage system (ThopazMedela, Baar, Switzerland). There were no postoperative complications, the chest drain was withdrawn on day 4, and the patient was discharged 24 hours later.
Comment The consequences of K-wire migration reported in the literature have been diverse and in some cases unusual. For example, pericardial tamponade, tracheal perforation, pulmonary artery lodging, pelvic bone migration, and intraspinal accommodation of K-wires have been reported [1–8]. The successful removal of intrathoracic K-wires using different approaches has been reported [8]. Which one is preferred depends on the location of the K-wire and the clinical condition of the patient. In emergent situations, or when damage to the heart or intrapericardial vessels is suggested, median sternotomy could be the first choice [2–4]. The preferred approach in light of the clinical condition and the viability reported by others would be thoracoscopic approach, as in this case study [5]. The mechanism of this silent migration into the right pulmonary hilum is not entirely clear. Although it has been described as peripheral intravascular embolization to the heart, this seems improbable in this case. Theories
Ann Thorac Surg 2015;100:1463–5
CASE REPORT BEAN ET AL ARTERIOVENOUS FISTULA AFTER NUSS PROCEDURE
1463
Fig 2. Chest computed tomography, mediastinal window, threedimensional reconstruction. The arrows show the position in the middle mediastinum and the cephalocaudal orientation of the wire going inside the lung parenchyma in left and right panels.
that include respiratory excursion or gravitational forces may be more relevant to this clinical presentation. Likewise, the movement favored by physical exercise could be added to the hypothesis of migration in this case. Certainly under any mechanism, the K-wire is able to reach any imaginable site in the body [6, 7]. In view of the multiple reports across the literature of complications after the use of K-wire, it is necessary to take preventive measures [8]. Some physicians recommend bending one tip of the wire to prevent its movement. For some authors, close clinical and radiographic postoperative follow-up examinations are essential after insertion of orthopedic wires, which should be withdrawn once treatment has concluded [2]. In conclusion, this case adds to the evidence that emphasizes the risks of K-wire use. It also shows the feasibility of the thoracoscopic approach when the clinical condition of the patient is stable.
References 1. Abbas A, Richmond N, McCormack DJ, et al. A 27-year-old man presenting with acute chest pain and dyspnea. Chest 2009;135:1684–7. 2. Zhang W, Song F, Yang Y, Tang J. Asymptomatic intracardiac migration of a Kirschner wire from the right rib. Interact Cardiovasc Thorac Surg 2014;18:525–6. 3. Anic D, Brida V, Jelic I, Orlic D. The cardiac migration of a Kirschner wire. A case report. Tex Heart Inst J 1997;24:359–61. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
4. Tubbax H, Hendzel P, Sergeant P. Cardiac perforation after Kirschner wire migration. Acta Chir Belg 1989;89:309–11. 5. Bezer M, Aydin N, Erol B, Lac¸in T, G€ uven O. Unusual migration of K-wire following fixation of clavicle fracture: a case report. Ulus Travma Acil Cerrahi Derg 2009;15: 298–300. 6. Foster GT, Chetty KG, Mahutte K, Kim JB, Sasse SA. Hemoptysis due to migration of a fractured Kirschner wire. Chest 2001;119:1285–6. 7. Lorenz G, Steinau G, Schumpelick V. [Intra-abdominal migration of a Kirschner wire from the femoral neck.]. Chirurg 1993;64:973–4. 8. Park S-Y, Kang J-W, Yang DH, Lim T-H. Intracardiac migration of a Kirschner wire: case report and literature review. Int J Cardiovasc Imaging 2001;27(Suppl 1):85–8.
Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum Jonathan F. Bean, MD, David Wax, MD, and Marleta Reynolds, MD Division of Pediatric Surgery, Department of Surgery, and Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
We report a case of a 13-year-old female patient who underwent the Nuss procedure for surgical correction of pectus excavatum. As a result of the procedure, the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.067
FEATURE ARTICLES
Fig 3. Thoracoscopic view. The introduction of the wire tip (long arrow) into the pericardial fat over the auricle (arrowhead) is shown on the left. The lung (thin arrow) and superior vena cava are shown (star). The ring clamp pulling the wire in the cephalic direction (star) is shown on the right.