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PubMed2002

Video-assisted thoracoscopic surgery in the treatment of chronic empyema thoracis.

We prospectively analyzed the surgical results in chronic organizing empyema thoracis utilizing a video-assisted thoracoscopic technique, particularly in debilitated patients. From January 1999 to September 2000, ten patients with stage III empyema thoracis underwent video-assisted thoracoscopic surgery for decortication (VATD). The mean age of the patients was 53.2 years, and they included one female and nine male patients. Four patients were regarded as not suitable for open thoracotomy. After the procedure, all patients had one infusion tube and two 32-F chest tubes inserted, the former for irrigation with saline solution and the latter for drainage. The mean operation time was 178 min. There was no mortality. The mean time to remove the infusion tube was 3.3 days. The mean time to remove the first chest tube was 7.1 days and the second chest tube 9.7 days. The mean hospitalization time after the operation was 14.9 days. The mean follow-up was 14.9 months. A restoration of lung function was ascertained in nine patients, with a 17.6% mean increase in forced vital capacity. There was no recurrence of empyema during the follow-up. Nevertheless, a reaccumulation of pleural effusion occurred in one patient 1 month after the procedure, which thus necessitated further treatment. VATD is considered to be a feasible surgical modality for the treatment of stage III empyema thoracis in selected patients.

Chest Tubes↗
PubMed1991

Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis.

As a sequel to a paper reporting good results obtained in 12 patients with empyema thoracis treated by thoracoscopic debridement and irrigation in our department, subsequent experience with a further 18 patients is reported. Drainage of pus and irrigation resulted in resolution of pyrexia with improvement in general condition in all patients. Overall, complete resolution was obtained by this technique alone in 60% (18/30). Of the 12 patients in whom complete resolution was not obtained, secondary surgical measures resulted in resolution of empyema in 8. Four patients died; all were elderly and severely debilitated, 3 with advanced malignancy. Their deaths were not related to the technique, which was well tolerated in all cases. Thoracoscopic debridement and irrigation used routinely as a first-line measure in empyema thoracis is a safe and relatively atraumatic procedure, does not exclude the use of any subsequent surgical measure, and provides valuable time to improve the condition of debilitated patients so that they may tolerate more aggressive surgical procedures.

Adolescent↗
PubMed1992

Thoracoscopic resection of an anterior mediastinal tumor.

The therapeutic role of thoracoscopy has expanded with advances in endoscopic surgical instrumentation and laser technology. We report a complete thoracoscopic resection of an encapsulated (stage I) thymoma with lymphocytic predominance in an elderly woman without myasthenia gravis. The patient had an uncomplicated postoperative course and was discharged on the third postoperative day. Median sternotomy with its attendant morbidity was avoided. Thoracoscopic resection of thymic neoplasms may be a useful approach in carefully selected patients.

Aged↗
PubMed1993

Thoracoscopic diagnosis and treatment of mediastinal masses.

Evaluation of mediastinal masses often involves an array of imaging procedures and percutaneous biopsy techniques. Despite this, surgical intervention with an open biopsy is often required, especially to diagnose mediastinal malignancies. We report 22 patients with mediastinal masses who were managed with thoracoscopic biopsy, as opposed to open biopsy. All of these patients either had unsuccessful fine-needle aspiration or were unacceptable candidates for percutaneous aspiration. The patients ranged in age from 11 months to 67 years with a mean age of 17.2 +/- 3.6 years. Thoracoscopy provided an accurate tissue diagnosis in 19 of the 22 patients (86%) without need for an open diagnostic procedure. In 1 patient, histoplasmosis was suspected from the thoracoscopic biopsy, but open thoracotomy was needed for confirmation. Of the 19 patients with a positive tissue diagnosis, 3 patients had bronchogenic cysts that were completely resected by thoracoscopy. The mean duration of chest tube drainage was 2.3 +/- 0.2 days, and there were no complications or procedure-related deaths. The average length of hospitalization was 6.0 +/- 0.8 days. We believe that thoracoscopy is a safe, rapid, and effective modality for the diagnosis of mediastinal masses. Accurate tissue diagnoses are obtained in most patients without the need for additional procedures. In addition, we have demonstrated that complete excision of certain benign lesions during thoracoscopy is possible.

Adolescent↗
PubMed1993

Thoracoscopic surgery: the Belgian experience.

Despite the already wide experience with video-assisted techniques in laparoscopic surgery, video-assisted thoracic surgery only recently came to be developed. This is clearly seen in a survey reflecting the experience among Belgian surgeons. A majority of the surgeons (63%) had limited experience (1 to 5 interventions), and only 28.5% had fairly considerable (between 11 and 20 interventions) or considerable (more than 20 interventions) experience. The majority of interventions performed were the treatment of pneumothorax, lung biopsies, wedge resections, and intrathoracic staging procedures, accounting for 209 (70%) of the 296 interventions collected in this survey. The remaining interventions display a wide variety of different thoracic procedures including lobectomy (4) and esophagectomy (20) for carcinoma. The overall technical success rate was 91% in this survey. Our own experience with 71 interventions or attempts reflects the same evolution with an overall technical success rate in 85% (60 patients). Pneumothorax was the most frequently performed intervention (35 patients), with a technical success rate of 94.5% (32 patients). Recurrences requiring further treatment occurred in 5 of the 32 patients (14.3%). All recurrences occurred before endostaplers were available, after which there were no failures in 12 consecutive cases. Other procedures successfully performed were lung biopsy/wedge resection (6), lung cancer staging procedures (3), lobectomy (1), hemothorax (3), chest wall neurinoma (2), sympathectomy (5), dorsal mediastinal neurinoma (1), thymectomy (1), esophagectomy (3), benign esophageal tumor enucleation (2), and Belsey Mark IV antireflux procedure (1). Furthermore, special emphasis was given to the development of video-assisted mediastinoscopy, which greatly facilitates teaching and interpreting this operation. Endoscopic myotomy using endostaplers was performed in 2 patients with Zenker's diverticulum. From our experience, however, it becomes clear that thoracoscopic approaches do not always result in a distinct benefit for the patient, as these procedures are more time consuming and usually require one-lung ventilation (probably the cause of the only fatal outcome in this series: a lung biopsy in an 85-year-old patient). In conclusion, video-assisted thoracic and thoracoscopic surgery is a new surgical modality offering new perspectives. However, careful patient selection and the same expertise as in open procedures are essential in determining the final outcome of each procedure.

Adult↗
PubMed1993

Video-assisted thoracoscopic resection of pulmonary metastases.

Pulmonary lesions in patients with malignancy often require resection to provide prognostic information and to dictate further therapy. Metastasectomy may also favorably influence survival in select patients with favorable tumor histologies. Seventy-two patients with a history of malignancy and new lung lesions identified by high resolution computed tomography underwent thoracoscopic resection. The operative approach was with standard techniques using two or three trocar sites. Preoperative needle localization was used in 13 patients with small lesions that were not immediately subpleural. All target lesions were identified at thoracoscopy. Exploratory thoracoscopy was followed by parenchymal sparing wedge resection with the endoscopic stapler, the neodymium:yttrium-aluminum garnet laser, or both. Histologic analysis revealed metastatic disease in 63 patients and benign disease in 9 patients. The mean diameter of the lesions was 1.6 cm. The mean duration of chest tube drainage and postoperative hospital stay were 2.1 and 4.1 days, respectively. Thoracoscopic resection appears to be a valid approach for diagnostic resection of presumed metastases. The role of thoracoscopy in therapeutic metastasectomy remains to be defined.

Chest Tubes↗
PubMed1993

Staged antrectomy and thoracoscopic truncal vagotomy for perforated peptic ulcer disease.

We report the case of a 40-year-old man with a perforated duodenal ulcer who underwent antrectomy at laparotomy, and in whom standard truncal vagotomy was not technically possible due to an intraabdominal abscess. Thoracoscopic truncal vagotomy performed at the level of the inferior pulmonary vein was successful in completely eliminating symptoms due to peptic ulcer disease without producing clinically significant morbidity. The minimal morbidity and short hospital stay suggest that thoracoscopic truncal vagotomy provides a reasonable alternative in patients with complicated intraabdominal abscesses due to peptic ulcer disease.

Adult↗
PubMed1995

Potential complications of vascular stapling in thoracoscopic pulmonary resection.

In a series of 57 patients undergoing thoracoscopic pulmonary lobectomy, 2 required expeditious conversion to open thoracotomy when a stapling device (Endo-GIA 30 V3; Autosuture, Ascot, UK) used on the main right lower pulmonary artery in 1 case and on the left superior pulmonary vein in the other cut but failed to staple the vessel involved. In both instances the vessel was successfully controlled while a thoracotomy was performed and the involved vessel was oversewn. Both patients made an uncomplicated postoperative recovery. As the number of thoracoscopic pulmonary resections increases, it is likely that similar episodes will occur in the future. These cases strongly emphasize the fact that patients undergoing this procedure should do so in a center specializing in thoracic surgery where there is the necessary surgical expertise and equipment to deal with such potentially life-threatening vascular complications.

Adenocarcinoma, Bronchiolo-Alveolar↗
PubMed1994

Thoracoscopic management of effusive pericardial disease: indications and technique.

Video-assisted thoracoscopic technique was evaluated in 28 patients who underwent operation for massive pericardial effusion. Excellent results were obtained using this newly developed approach for inspection of all pericardial surfaces as well as pleural and pulmonary disorders. No perioperative or postoperative complications ensued. Videothoracoscopy revealed positive lung malignancies in 11 patients, and these would not have been promptly diagnosed without thoracoscopy. Thoracoscopy also confirmed metastatic deposits on the pleura and diaphragm in 4 other patients. The visible nodules were proved to be metastatic adenocarcinoma. In 13 patients, thoracoscopy did not reveal malignancy, although 2 of these patients had a clinically suspected malignant lung tumor. Other indications for thoracoscopic drainage included 2 patients with impending pericardial tamponade after heart procedures and 6 patients with recurrent/loculated pericardial effusion. All of the patients showed promising and favorable postoperative courses after thoracoscopy. From our experience, video-assisted thoracoscopy was a safe and effective procedure, especially for those patients with combined pericardial effusion and abnormal pulmonary or pleural pathology in whom subxiphoid pericardial window was not clearly diagnostic at the time of operation. It was effective also in the situation with recurrent or loculated pericardial effusion which allowed localization and drainage of it. We believe that the use of videothoracoscopy to visualize the whole pericardial and pleural cavity will continue to be of great benefit to patients with combined pericardial and pleural/lung diseases.

Adenocarcinoma↗
PubMed1995

Thoracoscopic debridement of loculated empyema thoracis in children.

The appropriate management of multiloculated empyema thoracis remains controversial. During a 7-month period, we have managed multiloculated empyema with early thoracoscopic debridement in three consecutive pediatric patients. Chest tubes were removed 7 +/- 1 (mean +/- standard deviation) days after thoracoscopy and discharge from hospital was on postoperative day 8 +/- 1. We suggest that early thoracoscopic debridement of multiloculated empyema thoracis in children is safe and efficacious.

Adolescent↗
PubMed1996

Thoracoscopic obliteration of the left atrial appendage: potential for stroke reduction?

BACKGROUND: In a review of all relevant articles describing the site of left atrial thrombus in patients with atrial fibrillation, the thrombus was localized to the left atrial appendage in 43% of patients with rheumatic heart disease and in 91% of patients with nonrheumatic atrial fibrillation. This study was designed to test the feasibility of thoracoscopic obliteration of the left atrial appendage as a means of reducing thromboembolic stroke. METHODS: Thoracoscopic obliteration of the left atrial appendage was undertaken in 10 dogs, 5 with staples and 5 with an endoloop. Obliteration also was attempted in 8 fresh human cadavers. RESULTS: In all dogs, the appendage was rapidly obliterated (21.3 +/- 7.6 minutes) and confirmed at euthanasia at 11 weeks. In 3 cadavers, anatomic and disease factors prevented visualization of the left atrial appendage; in 1 the appendage tore, and in the remainder the appendage was obliterated. CONCLUSIONS: Obliteration of the left atrial appendage is feasible and may be considered as an additional surgical procedure to reduce stroke. The group of patients in whom it offers the greatest potential are those with atrial fibrillation deemed ineligible for warfarin, those without atrial thrombus and with a free pericardial and pleural space.

Animals↗
PubMed1996

Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis.

To facilitate initial visualization and subsequent mobilization of the thymus, adjuvant pneumomediastinum was preoperatively induced in 4 patients who underwent video-assisted thoracoscopic thymectomy. Neither mortality nor technique-related morbidity was observed. This experience shows video-assisted thoracoscopic thymectomy to be a safe and reliable procedure. In addition, we believe that adjuvant pneumomediastinum seems to facilitate the dissection maneuvers and could shorten operative time.

Endoscopy↗
PubMed1991

Thoracoscopic carbon dioxide laser treatment of bullous emphysema.

A new technique of thoracoscopic laser ablation of pulmonary bullae suitable for patients with multiple bullae and diffuse emphysema was developed and assessed in 22 patients. 20 of 22 patients survived. Pre-operative and postoperative functional evaluation is available for the 11 patients followed up for more than a month; at 1 to 3 months postoperatively there were increases in FVC (mean 2.0 litres pre-operatively to 2.7 litres postoperatively, p less than 0.001), in FEV1 (0.74 to 1.06 litres, p = 0.01), and in maximum exercise treadmill times (5.4 min to 8.0 min, p less than 0.01). Postoperative air leaks lasted a mean of 13 days and usually resolved spontaneously. Other complications were bleeding (1 patient) and unilateral acute lung injury (1 patient). These results suggest that selected patients with diffuse emphysema and pulmonary bullae may benefit from thoracoscopic carbon dioxide laser ablation.

Cysts↗
PubMed1995

Thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax.

Initial experience of thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax is reported. Thirty-three out of 49 patients admitted with spontaneous pneumothorax were suitable for treatment with this minimally invasive method. This series demonstrates that this surgical management offers early discharge and return to normal activities with excellent medium-term results, despite the three early failures. It is felt that with increased experience in thoracoscopy and improved selection of patients, thoracoscopic bullectomy and pleurodesis will become the treatment of choice for primary spontaneous pneumothorax.

Adolescent↗
PubMed1994

Video-assisted thoracoscopic treatment of pleural empyema. A new therapeutic approach.

Pleural empyema is a disease which is not always recognized. Despite consecutive treatment and antibiotics its mortality rate is still high, especially in older patients with concomitant disease or in the case of delayed treatment. We report our experience with early video-assisted thoracoscopic surgery of pleural empyema in 13 patients, where chest tube drainage had failed. The clinical symptoms of empyema did not exceed 14 days, bacteriologic cultures were positive in 62%. In all patients the fever disappeared within 1 to 5 days (mean 3.5) post-operatively and they remained in hospital for an average of 11.5 days after video-assisted thoracoscopic surgery. Pulmonary function tests 6 months later revealed normal values without a substantial loss of lung volumes. No relapse of empyema occurred.

Adult↗
PubMed2004

Effects of timing of thoracoscopic surgery for primary spontaneous pneumothorax on prognosis and costs.

BACKGROUND: Primary spontaneous pneumothorax recurs frequently. Timing of video-assisted thoracoscopic surgery to prevent recurrence is controversial and long-term costs remain inconclusive. METHODS: We constructed a Markov model to assess the effect of different timings for surgery on health status, costs, and cost effectiveness from the payers' perspective in Japan. RESULTS: During 1-year follow-up, the proportions of patients who underwent surgery after the first and second drainage were 46% and 36%, respectively. Average 1-year cost for surgery at the first episode was highest (U.S. dollars 6556), followed by the second (U.S. dollars 2988) and the third (U.S. dollars 2532). Incremental cost for surgery at the first episode compared with the second and that at the second episode compared with the third were U.S. dollars 30564 and U.S. dollars 29915 per quality-adjusted life year, respectively. Sensitivity analyses showed utility and length of hospital stay for surgery have the strongest effect on incremental cost. CONCLUSIONS: Thoracoscopic surgery at the first episode significantly increased costs, but could be acceptable from a cost-effectiveness perspective.

Adult↗
PubMed2005

Resection of a thoracic duct lymphangioma using video-assisted thoracoscopic surgery.

Thoracic duct lymphangioma is a rare mediastinal tumor. Most patients are asymptomatic. Symptoms may include dysphagia, dyspnea, cough, or chest pain. Workup may include chest computed tomography or lymphangiography, or both. Surgery should be considered the treatment of choice. We present a 60-year-old man with a 2.4-cm mass in the retro-cardiac space to the right of the esophagus. The patient underwent a thoracoscopic resection of the mass with ligation of the thoracic duct. We conclude that video-assisted thoracoscopic surgery allows for safe evaluation and resection of mediastinal pathology.

Humans↗
PubMed2004

Severity of compensatory sweating after thoracoscopic sympathectomy.

BACKGROUND: Compensatory sweating is a well-known side effect after sympathectomy for hyperhidrosis. It is often claimed to correlate with the extent of sympathectomy, but results from the literature are conflicting, and few have actually considered differences in the intensity of compensatory sweating. METHODS: A total of 158 patients underwent thoracoscopic sympathectomy for primary hyperhidrosis or blushing, or both. Sympathectomy was performed bilaterally at Th2 for facial hyperhidrosis/blushing (n = 49), Th2-3 for palmar hyperhidrosis (n = 62), and Th2-4 for axillary hyperhidrosis (n = 47). RESULTS: Follow-up by questionnaire was possible in 94% of patients after a median of 26 months. Compensatory sweating occurred in 89% of patients and was so severe in 35% that they often had to change their clothes during the day. The frequency of compensatory sweating was not significantly different among the three groups, but severity was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation. CONCLUSIONS: Compensatory and gustatory sweating were remarkably frequent side effects after thoracoscopic sympathectomy for primary hyperhidrosis. We found no significant difference between the level of sympathectomy and the occurrence of compensatory sweating. However, it appears that this is the first study to demonstrate that severe sweating is significantly more frequent after Th2-4 sympathectomy for axillary hyperhidrosis. We encourage informing patients thoroughly about these side effects before surgery.

Adolescent↗