Video-assisted thoracic surgery (VATS) is one of the main medical revolutions of the past decade. For its satisfactory performance, the following prerequisites are essential: (1) knowledge and experience in thoracic surgery; (2) team of experienced anesthesiologists; (3) preoperative assessment of respiratory function; (4) adequate postoperative care; and (5) instruments specially designed for thoracoscopic surgery. VATS is routinely performed under general anesthesia with double lumen endotracheal intubation for separate control of each lung. Insufflation of carbon dioxide must not exceed 1-3 mm Hg. Too high pressure may cause harmful reduction of venous return and mediastinal shift with impairment of ventilation. Presence of adhesions should be determined by finger exploration of the pleural cavity. Operative ports should be placed carefully, avoiding damage to the intercostal nerves and vessels. The video technique can be used with efficiency for the following indications: pneumothorax, resection of pulmonary nodules, biopsies of lung, pleura and mediastinal structures, resection of mediastinal tumors, management of empyema, and hemostasis and closure of lacerations after trauma. Indications for esophageal procedures include esophagomyotomy for achalasia and resections of benign lesions. Repair of perforated esophagus is a matter of controversy, but in early stages it can be done thoracoscopically. Although video-pericardioscopy has been performed by some surgeons, this procedure can be done easier and faster using the direct approach without the video equipment. There are differences of opinion with regard to major pulmonary and esophageal resections for cancer. The apparent advantage of diminished pain is offset by inadequate resection, spread of malignant cells and potential damage to the resected specimen with loss of important information concerning pathology. Complications of VATS are few, and include prolonged air leak, dysrhythmia, respiratory failure, bleeding and infection. Due to progress over the past several years, VATS has become an inseparable part of thoracic surgery and should be included in the basic training of every thoracic surgeon.

Humans↗

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The place of surgery in the treatment of re-emerging pulmonary tuberculosis.

BACKGROUND: A marked worldwide increase in prevalence of pulmonary tuberculosis occurred during the past 15 years. The reasons for this change include the worldwide epidemic of AIDS, poverty and unprecedented migration of people. METHODS: During the past 12 years, we operated on 57 patients with pulmonary tuberculosis or its sequelae. In 42 patients the disease was active at the time of operation. RESULTS: Two patients died of operative complications; one, of unrelated causes. There were three major non-fatal complications. In 49 patients tuberculosis was eradicated; five patients still have active disease and remain under drug therapy. CONCLUSIONS: High level of clinical awareness is the most important factor in disclosure and early treatment of pulmonary tuberculosis. Indications for operation are strengthened by alcoholism, drug abuse, poverty and other social factors. BCG vaccination of tuberculin-negative children should be considered as a preventive measure.

Adult↗

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Malignant thymoma invading pulmonary artery. Changing treatment options.

BACKGROUND: Curative treatment of malignant thymoma is resection; however, this may be precluded by invasion of vital organs. PATIENTS AND METHODS: Two patients with extensive intrathoracic spread of thymoma (Stages III and IV A) are presented. Treatment involved a combination of resection, radiotherapy and chemotherapy. RESULTS: One patient survived 9 years, 4 months, but eventually died of metastatic spread; the other one is well and without evidence of disease 30 months after treatment. CONCLUSIONS: Thymoma is a slow-growing tumor. Successful surgical treatment in advanced cases is possible, if aided by radiotherapy and chemotherapy. The adjuvant therapy converts a non-resectable tumor to a resectable one.

Adolescent↗

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Marlex mesh in giant ventral hernia repair.

Marlex mesh (polypropylene) is an excellent prosthetic material for closure of major defects in the abdominal wall. It helps to overcome many technical difficulties, making possible the repair of virtually every hernia. We describe two methods of ventral hernia repair, using Marlex mesh. In 20 operations in which one of the two methods was used, the results were uniformly satisfactory with acceptably low morbidity and no deaths.

Adult↗

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Bullous emphysema: guidelines for management and results of operative treatment.

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Adolescent↗

PubMedDate not supplied

Mediastinal staging of lung cancer: the changing role of mediastinoscopy.

In order to evaluate the role of mediastinoscopy in determination of resectability in lung cancer, we reviewed retrospectively our experience with this procedure. Of 936 mediastinoscopies performed during the past 22 years, 830 were performed for preoperative evaluation of patients with presumably resectable bronchogenic carcinoma. Metastases in superior mediastinal lymph nodes were found in 295 of 798 patients with histologically proven lung cancer (37%). These patients were spared an unnecessary thoracotomy. There was one death and no other major complications. Computerized tomography of the chest should be performed in all patients with bronchial cancer. If enlarged mediastinal nodes are demonstrated, mediastinoscopy is indicated for histologic evaluation of those nodes and for staging. Mediastinoscopy is a safe and highly reliable procedure with 100% specificity and over 90% accuracy, and is extremely important in staging and predicting resectability in lung cancer. It helps to avoid a futile thoracotomy in patients with incurable disease.

Carcinoma, Bronchogenic↗