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PubMed1993

Cost analysis for thoracoscopy: thoracoscopic wedge resection.

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1993

Thoracoscopy for empyema, bronchopleural fistula, and chylothorax.

The management of complications affecting the pleural space is sometimes technically demanding, but has been enhanced by the recent introduction of thoracoscopic techniques. An empyema in the fibrinopurulent phase is best managed by disruption of the loculations and complete drainage of the infected space. This is easily accomplished with the use of thoracoscopy, which also permits inspection of the pleural space to determine whether additional surgical intervention is required. In contrast, thoracoscopy is not indicated in the management of a free-flowing empyema or a chronic empyema associated with a fibrous capsule. Bronchopleural fistulas are occasionally treated by thoracostomy tube drainage alone, but, in most situations, surgical intervention is necessary to permit reclosure of the bronchus, coverage of the stump with vascularized tissue, and decortication or tissue flap rotation to fill the pleural space. These maneuvers are beyond the capabilities of current thoracoscopic techniques. Chylothorax is best treated initially by intercostal tube drainage and supportive measures. When surgical intervention is necessary to directly close a lymph vessel leak, thoracoscopic techniques have been successful in effecting closure, according to anecdotal reports.

Bronchial Fistula↗
PubMed1993

Thoracoscopy in the management of anterior mediastinal masses.

Thoracoscopy has been found useful for both the diagnosis and treatment of anterior mediastinal disorders. We have reserved it for use during thymectomy in the management of new-onset myasthenia gravis and for the resection of benign thymic, pericardial, and bronchogenic cysts. The application of thoracoscopic techniques in the anterior mediastinum should be approached conservatively. At this time, we believe it should be limited to diagnostic procedures requiring adequate biopsy and to therapeutic resections in which the extent of the resection is assured and therapeutic efficacy is maintained. We await further advances in both the instrumentation and technique before we are willing to undertake the performance of more radical resections using thoracoscopy. The efficacy of thoracoscopic thymectomy in the setting of myasthenia gravis awaits confirmation by larger clinical trials with adequate follow-up.

Bronchogenic Cyst↗
PubMed1976

Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds of the left lower chest: a preliminary report.

In an attempt to evaluate the place of thoracoscopy, the investigation was performed on 11 patients with penetrating wounds of the left lower chest, who had no definite clinical or radiological indication for operation. In 6 patients the diaphragm was seen clearly, and in 2 of these an unsuspected diaphragmatic injury was found. Both injuries were later confirmed at operation. The other 4 patients had intact diaphragms and were successfully treated conservatively. It is suggested that thoracoscopy is a useful aid in the diagnosis of left-sided, diaphragmatic injury and that the best results are obtained if it is performed within 24 hours of the injury.

Adult↗
PubMed2004

Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: results of a minimally invasive technique.

BACKGROUND: Several surgical methods have been described to treat achalasia with a recent trend toward utilizing minimally invasive techniques to perform a myotomy. Since 1998 our institution has utilized a minimally invasive thoracoscopy-assisted technique (ThAM) that allows a myotomy to be performed under direct visualization. METHODS: From 1992 to 2002, 57 patients underwent transthoracic Heller myotomy at our institution. Thirty-eight patients (67%) who underwent ThAM were reviewed and compared with 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM). RESULTS: There were no operative deaths in the ThAM group (n = 38) and 4 patients (11%) experienced minor morbidity. Four ThAM patients required conversion to open thoracotomy and 2 were lost to follow-up. Of the remaining 32 patients, 29 have improved postoperative dysphagia scores after a mean follow-up of 17 months. Only 4 patients have required further endoscopic or surgical intervention. Compared with the OM group, ThAM patients experienced significantly shorter average surgery time (97 versus 139 minutes), less blood loss (80 versus 155 mL), less postoperative narcotic requirement (8 versus 20 days), and shorter recovery to normal activity (20 versus 73 days). CONCLUSIONS: Thoracoscopy-assisted myotomy results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM. Shorter operating and recovery times as compared with OM without the need for an antireflux procedure makes ThAM an attractive minimally invasive technique.

Adult↗
PubMed2006

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors.

PURPOSE: The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision. METHODS: From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization. RESULTS: The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia. CONCLUSION: The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Bacterial Infections↗
PubMed2006

The Portsmouth thoracoscopy experience, an evaluation of service by retrospective case note analysis.

Occupational asbestos exposure has been endemic in Portsmouth. A retrospective case note analysis of 50 patients who underwent thoracoscopy over a 2-year period from January 2003 was undertaken. Biopsies were taken in 47 cases, 31 of which showed malignant mesothelioma. Thirty seven percent of those without a history of direct exposure to asbestos had mesothelioma, implying that even in the absence of an exposure history a low threshold for investigation should be adopted for the local population. There was no mortality or significant morbidity associated with the procedure. Medical thoracoscopy is safe and effective in the diagnosis of benign and malignant pleural disease particularly in this high risk population.

Aged↗
PubMed2000

Chest wall implantation of a mediastinal liposarcoma after thoracoscopy.

We report a case of mediastinal liposarcoma resected by thoracoscopy. Despite the precautionary measures, chest wall implantations occurred rapidly at the port's sites in the chest wall and led to death within 24 months. We conclude that thoracoscopy is not a good approach for resection of anterior mediastinal masses in view of their possible malignant character.

Adult↗
PubMed2002

Thoracoscopy before Jacobaeus.

In 1910 Jacobaeus described a procedure to which he referred as "Thorakoskopie." As a consequence, he is credited with having been the first to undertake an endoscopic exploration of the thorax. However, a published report by Gordon demonstrates that thoracoscopy was performed about 50 years earlier. Additionally in French, at least, the term "thoracoscopie" was well known long before Jacobaeus, although perhaps with a different meaning.

Europe↗
PubMed2001

Video-assisted thoracoscopy.

Thoracoscopy is a minimally invasive operative endoscopic procedure designed for visual inspection of the thoracic cavity. The use of small, highly maneuverable, rigid telescopes allows visualization beyond what is possible by standard operative techniques. The use of a small video camera attached to a standard rigid telescope allows the operator and assistants to view a simultaneous, enlarged, and clear image. This article focuses on the basic diagnostic and surgical techniques used in veterinary video-assisted thoracoscopy.

Animals↗
PubMed2001

Thoracoscopy in the pediatric patient.

The pediatric applications of minimally invasive surgical procedures such as thoracoscopy continue to increase. Specific alterations in anesthetic management may be required during the perioperative care of these patients. This article reviews the anesthetic care of infants and children during thoracoscopy with emphasis on cardiopulmonary disturbances of the patient, techniques to isolate the operative and nonoperative lungs and provide one-lung ventilation to improve surgical visualization, cardiopulmonary alterations induced by the creation of the artificial pneumothorax or the absorption of CO2 by the plural surface, intraoperative management of one-lung ventilation, and the potential for and treatment of inadvertent CO2 embolism.

Anesthesia↗
PubMed1997

Mediastinoscopy, thoracoscopy, and video-assisted thoracic surgery in the diagnosis and staging of lung cancer.

The surgical approach to the diagnosis and staging of lung cancer requires the assessment of the lung parenchyma, hilum, pleura, chest wall, and intrathoracic lymph nodes. Chest computerized tomography is sensitive in defining the location of the primary tumor, but is relatively insensitive to invasion. Similarly, radiographic imaging can identify lymph node enlargement, but lymph node enlargement alone is insufficient for accurate staging. To facilitate the tissue biopsies of both the primary tumor and potential sites of metastatic disease, video thoracoscopy has provided a useful complement to traditional bronchoscopy and mediastinoscopy. These instruments provide minimally invasive access to the lung, pleura, and ipsilateral lymph nodes. The combined application of thoracoscopy, bronchoscopy, and mediastinoscopy can provide intrathoracic staging information while minimizing surgical morbidity.

Humans↗
PubMed1997

Is there a role for video-assisted thoracoscopy in the staging of non-small cell lung cancer?

OBJECTIVE: To evaluate the role of video-assisted thoracoscopy (VAT) in the staging of non-small cell lung cancer (NSCLC). METHODS: In 30 patients (18 male, 12 female, median age 62 (50-78) years) VAT was used to assess the operability of NSCLC in cases where doubt existed after conventional staging investigations had been performed. RESULTS: VAT was used to assess direct tumour invasion of adjacent organs in 17 patients (mediastinal invasion in 14 and chest wall invasion in 3 patients). In 4 patients with limited respiratory reserve, VAT confirmed the need only for lobectomy prior to thoracotomy. Mediastinal lymph node biopsy was performed in 5 patients with significant (> 1.5 cm) lymphadenopathy on CT scan. VAT was also used to assess bilateral lesions in 4 patients with suspected synchronous tumours. Conversion to thoracotomy was necessary in 4 patients for technical reasons. Successful resection was possible in 17 of the remaining 26 cases, while unnecessary thoracotomy was avoided in 9 patients (30%) with unresectable or benign disease. In 4 patients deemed inoperable on CT scan, VAT staging enabled subsequent resection. CONCLUSIONS: Video-assisted thoracoscopy appears to have a complementary role in staging NSCLC when other methods are equivocal. It has the potential for increased sensitivity over conventional staging methods.

Aged↗
PubMed2002

The effects of intrathoracic pressure during continuous two-lung ventilation for thoracoscopy on the cardiorespiratory parameters in sevoflurane anaesthetized dogs.

The cardiopulmonary effects of different levels of carbon dioxide insufflation (3, 5 and 2 mm Hg) under two-lung ventilation were studied in six sevoflurane (1.5 minimum alveolar concentration; MAC) anaesthetized dogs during left-sided thoracoscopy. An arterial catheter, Swan-Ganz catheter and multianaesthetic gas analyser were used to monitor the cardiopulmonary parameters during the experiment. Baseline data were obtained before intrathoracic pressure elevation and the measurements were repeated at intervals after left lung collapse induced by insufflation with carbon dioxide gas. The intrapleural pressure levels used were 3, 5 and 2 mm Hg. Arterial blood pressures, cardiac index, stroke index, left and right ventricular stroke work index, arterial haemoglobin saturation, arterial oxygen tension and systemic vascular resistance decreased significantly during hemithorax insufflation, whereas heart rate, right atrial pressure, mean, systolic and diastolic pulmonary arterial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance and arterial carbon dioxide tension significantly increased during intrapleural pressure elevation. Although carbon dioxide insufflation into the left hemithorax with an intrapleural pressure of 2-5 mm Hg compromises cardiac functioning in 1.5 MAC sevoflurane anaesthetized dogs, it can be an efficacious adjunct for thoracoscopic procedures. Intrathoracic view was satisfactory with an intrapleural pressure of 2 mm Hg. Therefore, the intrathoracic pressure rise during thoracoscopy with two-lung ventilation should be kept as low as possible. Additional insufflation periods should be avoided, since a more rapid and more severe cardiopulmonary depression can occur.

Anesthetics, Inhalation↗
PubMed1997

Mediastinal tuberculous lymphadenitis diagnosed and treated by thoracoscopy.

Mediastinal tuberculous lymphadenitis is a relatively rare disorder and it is sometimes hard to identify the acid-fast bacilli involved or its specific pathological findings. We employed thoracoscopy to obtain diagnostic material from a 25-year-old woman with a newly-appearing mediastinal mass despite antituberculous therapy for cervical tuberculous lymphadenitis. Thoracoscopy also proved effective in the curative surgical procedure, i.e. resection of the abscess wall as far as possible, debridement of the remaining wall, irrigation, and instillation of streptomycin into the abscess and thoracic cavity. Postoperatively the patient has followed a favorable course for one year.

Abscess↗
PubMed1999

Early thoracoscopy for the evacuation of undrained haemothorax.

OBJECTIVE: To evaluate the accuracy of radiological tests and the outcome after thoracoscopic evacuation of retained haemothorax. DESIGN: Prospective study. SETTING: Academic trauma centre, USA. SUBJECTS: Of 703 patients with thoracic injuries, 58 (8%) were evaluated for and 15 (2%) were found to have, retained haemothorax. INTERVENTIONS: Plain chest radiographs (CXR) and thoracic computed tomograms (CT) 48 hours after admission, and thoracoscopic evacuation within 3-6 days of admission. MAIN OUTCOME MEASURES: Accuracy of radiological tests, morbidity, and mortality. RESULTS: 12 patients underwent early thoracoscopy with minimal morbidity, no mortality, and appreciable clinical and radiological improvement. Three patients who were not operated on developed empyemas. CXR was inaccurate in predicting the need for thoracoscopy. CT was the only test that predicted the need for evacuation of haemothoraces. CONCLUSION: Thoracoscopic evacuation of retained haemothorax is safe and effective. The success of the procedure is assured by early intervention in appropriately selected patients. CT is the ultimate test on which to base decision-making.

Adolescent↗
PubMed1993

Thoracoscopy in the diagnosis and management of chronic pleural effusions.

Thoracoscopy was performed in 76 patients with chronic pleural effusions in which thoracocentesis and blind needle biopsy failed to reach a precise diagnosis. Analysis of thoracoscopic biopsies provided a definitive diagnosis in 53 of the 76 subjects. The diagnoses included 35 malignant diseases in which the macroscopic appearance was diagnostic in only 27 patients. Among these 76 patients, a talc dusting was performed in the management of recurrent effusion in 33 patients. No recurrence of pleural effusion was observed after 1 month in 87% and after 6 months in 76% of patients with recurrent pleural effusion. We confirm that thoracoscopy is a safe and useful technique for the diagnosis of pleural effusion which substantially decreases the necessity for diagnostic thoracotomy and that talc dusting is effective to achieve pleurodesis.

Adolescent↗
PubMed2001

Thoracoscopy-assisted high intercostal percutaneous renal access.

PURPOSE: We describe a technique for safely accessing an upper pole calix through a 9th or 10th intercostal puncture. PATIENTS AND METHODS: A 9th or 10th intercostal access was used for percutaneous nephrolithotomy (PCNL) in nine patients. Thoracoscopy via the 5th or 6th intercostal space was used to ensure safe passage of the nephrostomy needle. RESULTS: Access was obtained in all patients without visceral injury. Seven patients were stone free after PCNL; the initial two required sandwich therapy to become so. Chest tubes were inserted routinely in the first eight cases. They were removed on postoperative day three and did not affect the length of hospital stay. CONCLUSIONS: Access through the 9th or 10th intercostal space is occasionally necessary and is ideal in certain circumstances. Thoracoscopy-assisted percutaneous renal access allows access under direct vision, thus preventing pulmonary injury.

Humans↗