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The authors report 21 cases of chronic duodenal ulcer treated by truncal vagotomy performed thoracoscopy. A description of the technique is presented. Mean feeding after surgery was 1.6 days. Mean hospital stay was 4.6 days (2-9). All patients were reviewed one month later by endoscopy and/or X Ray. There was no diarrhea or gastric outlet obstruction in this preliminary study.
Pleural mesotheliomas are uncommon tumors that can be classified as localized fibrous or diffuse malignant. The frequency in the general population is low and, as it concern the diffuse malignant type, exposure to asbestos, significantly increases the incidence. The most common symptoms are chest pain, short of breath and cough and the roentgenological findings are solitary or multiple pleural nodular lesions. The fibrous type can be excised and recurrence rarely occurs, but the malignant type does not respond either to chemotherapy or to radiotherapy and surgical measures offer only palliation. Thoracoscopy is a possibility of surgical excision in a case of localized mesothelioma and in case of diffuse type it contributes to the diagnostic yield, the open surgical procedures to be considered only in functionally operable patients.
MULTIFIRE ENDO GIA 30 was a newly auto suture developed by US surgical c.o., A 27-year-old man was admitted for right spontaneous pneumothorax in our hospital. We performed the partial resection of lung with this new auto suture under the thoracoscopy. Condition of patient after operation was very good, and he could discharge in short hospitalization. We concluded that this new auto suture was entirely reversible and safety.
We conducted this study in an attempt to investigate whether anatomic lobectomy can be performed through a thoracoscope. Twelve lower (seven left and five right) and six left upper lobectomies were done in 17 pigs weighing 60 to 90 kg. With the use of general anesthesia and one-lung ventilation, a thoracoscope and operating instruments were inserted through four or five trocars. First, the incomplete fissure was bluntly dissected with specially designed cotton-tipped dissectors and divided by an electrocautery spatula or sapphire contact-tip neodymium: yttrium aluminum garnet laser probe. The pulmonary artery and its branches were similarly dissected. Two ligatures were passed around the vessels by endoscopic right-angle clamps and tied by means of an extracorporeal tying technique. The vessels were clipped and divided. In two animals, a hidden branch of the pulmonary artery was inadvertently cut. Bleeding was readily controlled with the dissector until metal clips could be applied. The bronchus was similarly dissected and divided and the proximal stump was closed with sutures. The pulmonary vein was dissected bluntly by the same technique and divided. The excised lobe was placed in a plastic bag and pulled out through one of the trocar holes after the hole had been enlarged to 3 cm. Blood loss was minimal. In conclusion, anatomic lobectomy of the lung by means of thoracoscopy was feasible in the pig.
Examination by thoracoscopy, using flexible fiberoptic bronchoscope, was performed in 43 patients with pleural effusion according to our reported method. In these patients, 14 cases were diagnosed as tuberculous pleuritis. These 14 cases were investigated with respect to clinical and thoracoscopic findings. Their mean age was 38.1 years, and 11 cases were younger than 50 years old (78.5%). The male:female ratio was 2/1. Clinical symptoms recognised were fever (100%), cough (64.2%), chest oppression (50%) and sputum (35.7%). In 5 cases, gastrointestinal symptoms were recognized such as vomiting, abdominal pain, and diarrhea. Tuberculin reaction was positive in all patients with tuberculous pleuritis on admission. With respect to the thoracoscopic findings of tuberculous pleuritis, yellow-white miliary granulomas were observed on the parietal pleura in 12 cases (85.7%), and this characteristic finding was especially observed at the apex. Biopsy specimens, obtained from these miliary granulomas on the parietal pleura showed histological findings of tubercles. In the other 2 cases, generalized reddening of the entire parietal pleura was observed, with no yellow-white miliary granulomas. Biopsy specimens obtained from the reddened lesions on the parietal pleura showed histological findings of tubercles, and these 2 cases were also diagnosed as tuberculous pleuritis. These results indicate that this method may be very useful for the diagnosis of tuberculous pleuritis in patients with pleural effusion.
For a period of 35 months, 50 patients presenting with a total of 61 peripheral pulmonary nodules were operated on under videothoracoscopy. As a matter of principle none of these nodules were marked radiologically pre-operatively. All the scanners were reviewed retrospectively by a radiologist and a thoracic surgeon without knowing the results of the thoracoscopic intervention: 23 of these patients on the evidence would have quite obviously required preoperative marking (group I), and 27 would have been presented for direct thoracoscopy (group II). In group I there was only one group of nodules which could not be localised and by necessity, a thoracotomy was required. In group II, two nodules could only be localised thanks to a mino-thoracotomy. The level of failure was between 4 and 7%, and was identical to that found in the literature for different techniques of pre-operative radiological marking: these techniques were often complicated by a pneumothorax and intrapulmonary haemorrhage. These techniques for marking are used extensively. Prospective studies based on precise and complete criteria should enable better definition of rare cases which might benefit.
Although thoracoscopy is not a new procedure, there was a real revival after the introduction of laparoscopy. VATS (video-assisted thoracic surgery) has potential advantages of reduced pain due to smaller incisions and a shorter hospital stay. Main disadvantages are expensive equipment and a probably less adequate operation, especially for therapy of malignant disorders where long-term results are not known. VATS is very useful for investigation of pleural effusion and malignancy. Spontaneous pneumothorax is a very good indication for thoracoscopic treatment, as well as lung biopsy and diagnostic resection of lung metastases. Therapeutic metastasectomy, however, should not be performed by VATS. Regarding bronchogenic carcinoma, VATS is indicated for staging of lung cancer, facilitating sampling of mediastinal and hilar lymph nodes, investigation of pleural effusion, possible pleural dissemination and suspicion of intrapulmonary metastases. Wedge excision of solitary pulmonary nodules by VATS readily reveals the exact diagnosis, but its role in therapy of lung cancer is very limited at the present time.
OBJECTIVES: Neck exploration is usually required in all cases of primary hyperparathyroidism. Without a precise localization preoperatively cervicotomy may be unsuccessful, especially in case of an ectopic adenoma. CASE REPORT: A patient with primary hyperparathyroidism due to a solitary adenoma localized in the middle mediastinum was identified on preoperative computed tomography and technetium-99m-sestamibi radionuclide scan. The tumor was successfully removed at thoracoscopy without neck exploration. DISCUSSION: Preoperative localization of primary hyperparathyroid tumors is not indicated in all patients. In some selected cases (acute hypercalcemia, reoperation, serious illness) prior neck exploration would be useful in guiding the surgeon.
The management of patients who present with penetrating thoracic trauma but are haemodynamically stable may be subjective and imprecise. We report our initial experience with the use of video-assisted thoracoscopy in a series of five patients in whom accurate assessment was achieved and unnecessary thoracotomy avoided.
When performing thoracoscopy in patients with pleural effusion of unknown origin, we used two bronchoscopes simultaneously, one for observation and one for biopsy. A total of 50 patients with pleural effusion of unknown origin were studied. In all of those studies, pleural effusion was exudative, lymphocyte-dominant, had a low level of adenosine deaminase, no malignant cells, and no tuberculosis or other bacteria in pleural effusion smears. Fourteen were out-patients. A catheter was inserted into the pleural space under local anesthesia, and 300 ml to 500 ml of pure oxygen was injected to create a pneumothorax. Two flexible fiberoptic bronchoscopes were used simultaneously, one for observation and one for biopsy. Approximately 1 hour after the examination, the out patients were able to return home. Lesions in the pleural cavity were found in 42 of these 50 patients, and histological diagnosis was possible in 46. This is a simple procedure with no major side effects. The equipment required is familiar to pulmonary physicians, and the diagnostic yield is high.
Many patients who once were considered for open chest procedures now benefit from examination and treatment of pleural disease via thoracoscopy. The thoracoscopist enters the chest cavity through small incisions through the chest wall. Procedures are performed through a video assisted thoracoscope (much like a bronchoscope or endoscope). Wound care, maintenance of the chest drainage system, pain management and vigilant assessment of the cardiorespiratory system following the procedure are integral nursing interventions when caring for these patients.
To reduce the high morbidity rate associated with esophagectomy for esophageal cancer, thoracoscopic approach has been recently introduced. However thoracoscopic esophagectomy has been performed as a palliative operation like the transhiatal esophagectomy. We have developed a technique of video-assisted thoracic surgery (VATS) using thoracoscopy or mediastinoscopy as a radical esophagectomy. For the extensive lymph node dissection, especially along bilateral recurrent nerves, could be successfully performed in more than 20 patients by VATS with thoracoscopic instruments through the usual thoracotomy. And we have also applied VATS with small thoracotomy to the radical esophagectomy. Using this technique, we could performed esophagectomy almost same as the radical esophagectomy through usual thoracotomy even in small number of cases. Furthermore, disadvantages of the transhiatal esophagectomy, inherent in the blind dissection involved, was almost conquered by VATS using mediastinoscopy. These initial results of ours indicate that video-assisted esophagectomy is a feasible procedure as the radical operation for esophageal cancer.
For many years, treatment of spontaneous pneumothorax (SP) has been a matter of debate. Since the introduction of videothoracoscopy, videothoracoscopic procedures have replaced thoracotomy as the ultimate procedure for treatment of complicated cases of SP in many institutes. However, the place of (video) thoracoscopy in SP has not been fully established yet. Satisfactory results have been published about several different combinations of bullectomy (Stapler resection, endoloop ligation, electrocoagulation, Nd-YAG laser, CO2 laser, argon beam coagulation) and pleurodesis (mechanical, chemical, pleurectomy). Until today, it remains obscure if bullectomy as well as pleurodesis are always necessary to prevent recurrence.
This article presents the current status of thoracoscopy in clinical practice. Aspects of its use in diagnostic, staging, and therapeutic areas are reviewed as regards diseases of the pleura, lung, and mediastinum. Controversies and evolving applications are identified.
Using video-assisted thoracoscopic techniques in 32 lung cancer patients over the past 3 years, we have performed a vriety of procedures previously accomplished by "open" techniques. This group of patients included stage I (7 patients), stage II-IIIa (10), stage IV (15). Our procedures include wedge resections of lung tumor using endoscopic mechnical stapling devicesin 7 patients; pulmonary lobectomy in 7; lung cancer staging in 7; pleural biopsies and pleurodesis in 11. There were no mortality and no serious complications associated with the procedure. Our experience indicates on expanded role of thoracoscopy in the diagnosis and treatment of lung cancer.
Video-assisted thoracoscopy (VATS) is useful for improving preoperative diagnosis and staging in patients with peripheral pulmonary lesions. Additional information obtained by VATS had a major influence on the therapeutic strategy in 34% of the patients, and in 39% of the patients in the conventional surgery group thoracotomy could possibly have been avoided if VATS had been available.
Medical thoracoscopy is an efficient technique to evaluate the gravity of a spontaneous pneumothorax in order to choose the most appropriate treatment. Classification of lesions into four types (from endoscopically normal lungs to large bullae) guides the choice from local talc pleurodesis to surgical bullectomy and pleurectomy. Most patients with the first three types can be treated with talc pleurodesis, with a good success rate (93%) and no functional sequelae (lung volumes within the normal range in primary pneumothorax and similar to previous values in secondary pneumothorax). Neuroleptanalgesia in association with patient-controlled analgesia appears to be superior to local anaesthesia in the prevention of immediate pain induced by talc poudrage. Talc pleurodesis is the treatment of choice for recurring spontaneous pneumothorax because of its high success rate and absence of complications.
A number of unusual or uncommon thoracoscopic indications have developed over the years. Pleural tuberculosis and blastomycosis, HIV infections, histoplasmosis, presenting as a nodular process have been diagnosed and treated. Fistulae or tube tract endoscopy may delineate whether a patient has persistence or recurrent carcinoma or tuberculosis through biopsy and culture techniques especially in the post pneumonectomy patient with an air leak. Thoracic diseases, including carcinoma, and mediastinal adenopathy and undiagnosed masses, are amenable to biopsy and possible resection. Foreign bodies may be removed with this technique. The utilization of thoracoscopy for diagnosis and treatment of pericardial processes has been utilized as well for placement of pacemakers. More recently, internal mammary artery to coronary artery bypass grafting has been performed by a few same surgeons with the endoscopic or VATS technique. Neurogenic indications include resection of the posterior sympathetic ganglia and vagectomy. Chylothorax therapy utilizing fibrin glue and liver and kidney biopsy may be performed.