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PubMed2003

Unilateral brachial plexus injury as a complication of thoracoscopic sympathectomy for hyperhidrosis: a case report.

Unilateral brachial plexus injury is a rare complication of thoracoscopic sympathectomy, which is generally considered to be a simple and safe procedure. We report on a 26-year-old man who developed weakness and numbness of the right arm after thoracoscopic sympathectomy for hyperhidrosis. Electromyographic study revealed evidence of denervation in the upper trunk of the right brachial plexus. A nerve conduction study on the right axillary nerve revealed a reduced compound muscle action potential amplitude at the right deltoid muscle. We suggest that this complication was caused by stretch and/or compression when the arm was hyperabducted during the operation. The outcome was excellent, with almost complete recovery 3 months later. The complication can be prevented by minimizing operation time and avoiding hyperabduction of the arm. The prognosis for postoperative brachial plexopathy is usually good with conservative management.

Adult↗
PubMed1996

The safety and efficacy of thoracoscopic lung biopsy for diagnosis and treatment in infants and children.

Thoracoscopic techniques were used to perform lung biopsies and limited resections in 36 consecutively treated cases. Biopsies were performed for interstitial lung disease in 27 cases, presumed metastatic lesions in 5, and cavitary lesions in 4. Histological diagnosis was obtained in 35 of the 36 cases, and therapy was directly affected by the results in 30 of 36 cases. There were no postoperative complications, and the average hospital stay for patients admitted the morning of surgery was less than 2 days. Limited thoracoscopic resection provides a safe and effective means for diagnosing and treating parenchymal disease of the lung.

Adolescent↗
PubMed1998

Thoracoscopic anterior spinal procedures in children.

METHODS: From February 1996 through July 1997, 20 patients were determined to be appropriate for a thoracoscopic approach for the anterior portion of their spinal surgery. Ages ranged from 8 to 17 years of age and weight from 20 to 70 kg. The diagnosis included severe idiopathic and neurogenic scoliosis or kyphosis (n = 20) and congenital hemivertebra (n = 4). The procedures performed included diskectomy and anterior release from two to nine vertebral levels, hemivertebrectomy, and epiphysiodesis. Four patients also had an open lumbar exposure and all had a posterior fusion. RESULTS: All procedures were completed successfully endoscopically. Surgical times for the thoracoscopic portion of the procedure averaged 106 minutes and total procedure times were comparable with the standard open technique. Three patients were extubated at the end of the procedure with the majority extubated on postoperative day 1. Average intensive care unit stay was 1.8 days, and chest tubes were removed between postoperative day 1 and 5 (average, 2.2 days). In follow-up, surgical correction was deemed to be acceptable and equivalent to open techniques in all cases. CONCLUSION: This technique has proven to be safe and effective in children and appears to be associated with less pain and morbidity as evidenced by earlier extubation and chest tube removal and shorter ICU stay.

Adolescent↗
PubMed1996

Unilateral thoracoscopic surgical approach for diffuse emphysema.

We evaluated the use of a lateral thoracoscopic approach for lung reduction surgery in patients with diffuse emphysema. Sixty-seven patients with a mean age of 61.9 years underwent operation. Operative side was determined by preoperative imaging. The procedures were laser ablation in 10 patients and stapler resection in 57 patients. Ten patients, including six of the 10 patients in the laser-only group had poor outcome (death or hospitalization longer than 30 days), leading us to abandon the laser technique. Of the remaining 57 patients undergoing primary stapled resection, duration of chest tube placement averaged 13 days (range 3 to 53 days) with a mean hospital stay of 17 days (range 6 to 99 days). Seven patients required ventilation for longer than 72 hours, six patients underwent conversion of the procedure to open thoracotomy, four patients acquired arrhythmias, and three patients were treated for empyema. There was one early death (1.7%), from cardiopulmonary failure. Forty patients returned for 3-month evaluation. Significant (p < 0.0001) improvements were seen in forced vital capacity (2.69 L after vs 2.26 L before) and forced expiration volume in 1 second (1.04 L after vs 0.82 L before), with 25 of 40 patients (63%) showing an improvement of more than 20%. Lung volume measures, in particular residual volume, fell significantly. Arterial blood gas analysis revealed that carbon dioxide tension fell significantly in patients with preoperative hypercapnia (carbon dioxide tension > 45 mm Hg, p = 0.018). Six-minute walk test results improved (894 feet after vs 784 feet before, p = 0.002), and symptomatic benefit was confirmed by significant improvement in the dyspnea index. The combination of both hypercapnia and reduced single-breath diffusing capacity for carbon monoxide was significantly more frequent (p = 0.0026) and was 86% specific (5 of 6 patients) in predicting serious postoperative risk. We conclude that the lateral thoracoscopic surgical approach to diffuse emphysema offers significant improvement in pulmonary mechanics and functional impairment. Patients with a combination of hypercapnia and reduced single-breath diffusing capacity for carbon monoxide should not be considered for this procedure because of significant perioperative risk.

Adult↗
PubMed1996

Thoracoscopic splanchnicectomy for chronic pancreatitis pain.

BACKGROUND: The study was undertaken to quantitate the effects of thoracoscopic splanchnic nerve resection (SPL) on pain from chronic pancreatitis. METHODS: Patients with chronic pancreatitis pain completed an analog pain scale before operation and at postoperative visits. Midepigastric and left-sided pain was treated with left SPL; right-sided pain was treated with right-sided SPL. If pain recurred on the contralateral side, the patient underwent contralateral SPL. RESULTS: Fifteen patients underwent SPL. Eleven patients required daily narcotics for relief of pain before operation. Eight patients had unilateral SPL, whereas seven ultimately had a bilateral operation (median follow-up, 18 months). Fourteen patients had constant pain before operation, which decreased to a mean of 2.8 attacks per month (p < 0.0001). Before operation, the "worst pain within last two months" was 9.1 on pain scale (range, 0 for no pain, to 11 for constant pain). After operation this decreased to 5.1 (p < 0.002). "Current severity" of pain decreased from 6.5 before operation to 2.0 after operation (p < 0.0005). The "amount pain is interfering with daily activities" decreased from 7.3 before operation to 2.3 after operation (p < 0.0001). Seven patients (46%) no longer require narcotics and are classified as having had good results. Five patients (33%) are classified as improved and have had a major reduction in narcotic needs. Three have had no significant pain relief and are classified as having had poor results. CONCLUSIONS: Thoracoscopic SPL offers substantial promise in the therapy of pain from chronic pancreatitis.

Adolescent↗
PubMed1997

Thoracoscopic esophagectomy for esophageal cancer.

BACKGROUND: Minimal access surgery is an alternative to open surgery in esophageal surgery. Its role in cancer resection is controversial. METHODS: Thoracoscopic esophageal resection was attempted in 22 patients who had increased operative risk. Postoperative outcomes of these patients were compared with the outcomes of 63 patients who underwent open thoracotomy resection during the same period. RESULTS: Thoracoscopy was completed in 18 patients. Conversion to thoracotomy was necessary because of locally advanced tumor in three patients, and a bypass procedure was performed in another patient because of poor ventilation during thoracoscopy and the finding of metastatic disease. The median thoracoscopy time was 110 minutes (range, 55 to 165 minutes). The total operating times were 240 minutes (range, 165 to 360 minutes) and 250 minutes (range, 190 to 420 minutes) for thoracoscopy and thoracotomy, respectively, p = 0.5. Blood loss was significantly less than that of open resection; medians were 450 ml (range, 200 to 800 ml) and 700 ml (range, 300 to 2500 ml) for thoracoscopy and thoracotomy, respectively, p < 0.01. The median number of lymph nodes removed at thoracoscopy was 7 (range, 2 to 13) compared with 13 (range, 5 to 34) in the thoracotomy group. Bronchopneumonia affected 17% of both groups of patients. Only one patient who was converted to open thoracotomy died. Port site recurrence developed in one patient. Overall survival rates were not significantly different. CONCLUSIONS: Thoracoscopic esophageal resection was a feasible option. Clear advantages over open thoracotomy were not demonstrated, although patients who were selected for thoracoscopy had worse performance status. This technique deserves further investigation in dedicated centers.

Adult↗
PubMed2002

Thoracoscopic monitoring for pericardial application of local drug or gene therapy.

UNLABELLED: Cardiovascular gene therapy is a promising new approach for a variety of diseases. As far as gene therapy aimed at the myocardium is concerned a new transcutaneous delivery method may be into the pericardial sac. OBJECTIVE: To evaluate the safety and applicability of the percutaneous pericardial delivery route for drug- or gene-therapy. METHODS: A percutaneous pericardial access device called a perducer was used to deliver either Indian ink or methylene blue to the pericardium of male yorkshire pigs under hemodynamic surveillance. Animals were sacrificed after either 3 h or 3 days. Post mortem distribution of the injectate was evaluated macroscopically and microscopically. RESULTS: With the perducer, the pericardial cavity was punctured in 10 pigs without hemodynamic complications. Although traces of dye could be seen in the pleural cavity in pigs sacrificed after 3 h, no evidence for dissemination was found in myocardial, lung, mediastinal lymph node and liver tissue in pigs sacrificed after 3 days. In two additional pigs the pericardium was punctured with the same perducer technique under simultaneous thoracoscopic monitoring. Visualization of the surface of the pericardium facilitated the procedure because pericardial fat could be avoided. CONCLUSION: Obtaining access to the pericardium with the perducer technique is safe and feasible. In addition thoracoscopic guidance may improve success rate and offers the possibility of on line surveillance.

Animals↗
PubMed1999

Thoracoscopic surgery and pleurodesis for pleuroperitoneal communication in patients on continuous ambulatory peritoneal dialysis.

Two patients on continuous ambulatory peritoneal dialysis (CAPD) developed right massive hydrothorax and were diagnosed as having pleuroperitoneal communication. Thoracoscopic surgery and pleurodesis were performed. It showed that one was caused by multiple flaws in the diaphragm and that the other was attributable to multiple blebs in the diaphragmatic dome. After the procedure, both of them had no recurrence of hydrothorax and underwent CAPD safely. We recommend thoracoscopic surgery and pleurodesis as the first choice of therapeutic methods for pleuroperitoneal communication.

Endoscopy↗
PubMed1995

[Correlation between sensitivity of the cytogenetic and cytological analysis and thoracoscopic findings in the study of malignant pleural effusions].

We studied 104 patients with pleural effusion. All underwent thoracoscopic exploration to allow direct examination of any pleural lesions present. At the same time pleural biopsies for histopathologic study and samples of pleural fluid for cytopathologic and cytogenetic study were taken. The volume of fluid in pleural cavity was also measured. The aims of the study were: a) to evaluate the sensitivity of cytogenetic analysis and cytopathology, both separately and together, and b) to look for a correlation between the sensitivity of these cell studies and the following thoracoscopic findings: tissue biopsy of pleural neoplasms, volume of pleural effusion and extension of neoplastic lesions in the pleural cavity. Seventeen of the pleural liquids studied were benign and 87 were neoplastic. Cytopathology was sensitive in 55% of the neoplastic cases and cytogenetic study was sensitive in 49%. Sensitivity rose to 74% when both techniques were applied. Cytogenetic study yielded a higher percentage of correct diagnoses in the group with hematologic neoplasia, whereas cytopathology was correct more often in cases of solid tumors, though these differences were not statistically significant. Use of both techniques resulted in correct diagnosis in 92% of patients with mesotheliomas. The number or correct diagnoses achieved with cytopathology tended to increase with size of macroscopic pleural lesion whereas cytogenetic study was more sensitive in patients with minimal or incipient pleural involvement. There were no statistically significant differences in sensitivity of cytopathology and cytogenetic analysis with regard to volume of pleural effusion.

Adolescent↗
PubMed2001

Video-assisted thoracoscopic treatment for pleuroperitoneal communication in peritoneal dialysis.

Massive hydrothorax is an uncommon but well-recognized complication of continuous ambulatory peritoneal dialysis (CAPD). We performed a video-assisted thoracoscopic resection of the pleuro-peritoneal communication and pleurodesis in a patient with massive right hydrothorax secondary to CAPD. Histologically, the resected diaphragm was lacking in common tissue, tendons and skeletal muscle tissues, is displaced to fibrous connective tissue. These anatomic findings suggested that the cause of communication was congenital diaphragmatic change. Video-assisted thoracoscopic treatment facilitated efficient inspection and easy resection of the weak portion of the diaphragma in the case of pleuroperitoneal communication.

Humans↗
PubMed2002

Long-term outcome of staged versus one-stage bilateral thoracoscopic reduction pneumoplasty.

OBJECTIVE: In a prospective non-randomized study, we tested the hypothesis that unilateral reduction pneumoplasty followed by completion of bilateral treatment at the reappearance of symptoms might result in more sustained improvements and better survival than one-stage bilateral treatment. METHOD: Fifty-nine patients undergoing bilateral thoracoscopic reduction pneumoplasty as a one-stage (n=33) or staged (n=26) procedure were evaluated on. The main indication for staged reduction pneumoplasty was symptom deterioration after unilateral treatment for asymmetric emphysema. Complete clinical assessment was carried out preoperatively and every 6 months postoperatively. RESULTS: The mean length of follow-up was 34+/-15 months. Interval time between operations in the staged group averaged 15.2 months. There was no inter-group difference in baseline data. Peak improvements in forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC) and residual volume (RV) was significantly greater following one-stage bilateral reduction pneumoplasty. In particular, Delta FEV(1) was 0.33+/-0.2 l in the staged group and 0.43+/-0.2 l in the one-stage group (P=0.007). At 48 months, FEV(1), RV and 6-min-walking-test (6MWT) were still significantly improved only in the staged group. Four-year survival was 70% in the staged group and 81% in the one-stage group (Cox-Mantel test, P=not significant). CONCLUSION: Durable physiological improvements and satisfactory survival were achieved in this study for up to 4 years following either staged or one-stage bilateral reduction pneumoplasty using thoracoscopic technique. However, while peak improvements in FEV(1), FVC and RV were significantly greater following one-stage bilateral reduction, long-term improvements in FVC and 6MWT were more stable following a staged procedure. We speculate that sequential unilateral reduction pneumoplasty may reduce the mechanical stress in the lung leading to less steep postoperative deterioration of respiratory function.

Aged↗
PubMed2002

New operative method for a giant bulla: sutureless and stapleless thoracoscopic surgery using the Ligasure system.

Thoracoscopic bullectomy performed with staplers is the main treatment for giant bullae in many institutions. However, there are certain problems associated with the increasing use of stapling devices. In response, we have applied a new operative method in which we excised a bulla with an ultrasonic-driven scalpel and successfully sealed the cut ends using the LigaSure Vessel Sealing System, a new bipolar system developed by Valleylab Inc. Herein we describe our experience with this newly designed technique which could render possible 'sutureless and stapleless' thoracoscopic surgery in the future.

Adult↗
PubMed1998

Unilateral thoracoscopic reduction pneumoplasty for asymmetric emphysema.

OBJECTIVE: We prospectively analyzed the surgical and functional results of unilateral thoracoscopic reduction pneumoplasty which we performed by choice in patients with asymmetric emphysema. METHODS: Between October 1995 and June 1997, 119 emphysematous patients were examined and 34 were operated upon. Among these, 14 selected patients with asymmetric distribution of emphysema in the lungs underwent unilateral reduction pneumoplasty (ten right, and four left). There were 13 males and one female, with a mean age of 62 years. Eligibility criteria included bullous and non-bullous end-stage emphysema with severe limitation to daily activity. RESULTS: No patient required conversion to thoracotomy. Mean operative time ranged between 70 and 240 min with a mean of 103 min. There was no postoperative mortality but five patients developed one or more complications: five prolonged air leaks (>7 days); two pulmonary infections; one empyema. No patient required postoperative mechanical ventilation. Median hospital stay was 8 days. At the 3-month follow-up the mean FEV1 increased from 0.8 l to 1.2 l (P < 0.001). Mean FVC increased from 2.6 l to 2.9 l (P < 0.001). The Medical Research Council dyspnea score decreased from a mean of 3.2 to 1.8 (P < 0.001). CONCLUSIONS: Asymmetric distribution is a frequent finding in patients with severe emphysema. Unilateral thoracoscopic reduction pneumoplasty may represent an ideal approach in this selected group of patients.

Aged↗
PubMed1999

Comparison of thoracoscopic and laproscopic esophagomyotomy with fundoplication for primary motility disorders.

OBJECTIVES: With the introduction of videoscopic techniques, controversy has arisen whether a thoracoscopic or laproscopic approach is indicated for the surgical management of symptomatic primary motility disorders. The aim of this study was to compare the outcomes of the two techniques performed by one group. METHODS: Between 1995 and 1997, 78 patients (42 female, 36 males: ages 21-86; mean 53 years) underwent a videoscopic esophagomyotomy with fundoplication via a thoracic (12) or abdominal (66) approach for dysphagia or chest pain. Pre-operative evaluation with esophagogastroscopy and manometry revealed a primary motility disorder in 64 and primary motility disorder with stricture in 14. Primary motility disorders exhibited were hypertensive LES (25), nutcracker (26), achalasia (14), and diffuse esophageal spasm (13). Associated fundoplications to prevent reflux included abdominal Toupet partial fundoplicatio (52), abdominal Nissen (14) and thoracic Belsey (12). Significance of variation in outcomes was determined by Mann-Whitney U-test. RESULTS: There was no mortality. Follow-up ranged from 6-40 months (mean = 18). Early morbidity included dyshagia--chest pain greater than 6 weeks in 16 patients. (5 Belsey 41%, 10 Toupet 19%, 1 Nissen 7%) Late morbidity included three recurrent strictures requiring dilatation (Belsey 2/5, Toupet 1/7). Two patients (3.1%) experienced a recurrent motility disorder after abdominal short myotomy--Toupet. Five patients experienced postoperative gastroesophageal reflux after partial fundoplication (two Belsey = 16.6%, three Toupet = 5.7%). Overall 63 patients (81%) were completely relieved of dysphagia--chest pain. CONCLUSIONS: Thoracoscopic esophagomyotomy with Belsey fundoplication was associated with a significantly higher incidence of post-operative dysphagia--chest pain (P = 0.05) and recurrent stricture (P = 0.01 ) than laproscopic esophagomyotomy with partial or total fundoplication, however, there was no significant difference in the incidence of recurrent motility disorders (P = 0.54) or gastroesophageal reflux disease (P = 0.12) between the techniques. Our results support utilization of a laproscopic approach for primary motility disorders.

Adult↗
PubMed1999

Video-assisted thoracoscopic sympathectomy for severe intractable angina.

OBJECTIVE: Endoscopic trans-thoracic sympathectomy is a well documented, safe and successful treatment for palmar and axillary hyperhidrosis. This may also be helpful in the management of patients with intractable angina and advanced coronary disease unsuitable for coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA). We evaluated video assisted thoracoscopic sympathectomy (VATS) in such patients with the aim of improving symptoms and quality of life. METHODS: Video assisted thoracoscopic sympathectomy, a minimally invasive procedure, was performed under general anaesthesia with alternating single lung ventilation. Three stab incisions were made at the level of the fourth intercostal space in the anterior and posterior axillary lines, and at the fifth intercostal space in the mid-axillary line through which an extensive thoracic sympathectomy was performed to include second to the fourth ganglia, bilaterally. RESULTS: A total of 16 patients aged 46-76 (mean 61) years were assessed for VATS. Of these 10 patients had the procedure performed; nine with previous CABG and one with diffuse coronary disease. Six patients were excluded because of an evolving MI (n = 1), left ventricular ejection fraction (LVEF) < 30% (n = 2), and chronic stable angina with no objective evidence of ischaemia (n = 3). All 10 patients had marked symptomatic improvement with reduction of both angina frequency and intensity of attacks. Mean follow-up period 11.5 months. Exercise tolerance and time to onset of angina measured on exercise treadmill was significantly increased post-VATS (P = 0.028) and maintained 1 year post-operative. CONCLUSION: VATS was associated with both reduction in angina symptoms and an increase in exercise time to onset of angina. An improved quality of life was evident.

Aged↗
PubMed1998

Timing of video-assisted thoracoscopic debridement for pediatric empyema.

BACKGROUND: Video-assisted thoracoscopic debridement (VATD) is a new method of managing pediatric empyema. The purpose of this retrospective study was to determine the relation between the timing of VATD and its success in avoiding the need for open decortication. STUDY DESIGN: Twenty-one children aged 3 to 16 years (mean, 8 years) with symptomatic, loculated, parapneumonic empyema were treated with VATD at two tertiary pediatric centers between 1994 and 1997. The preoperative duration of symptoms, hospitalization, and previous need for thoracostomy drainage were compared between patients having VATD only and those who subsequently required a thoracotomy and decortication. Statistical analysis used the Wald chi-square test or Fisher's exact test with p < 0.05 considered significant. RESULTS: Video-assisted thoracoscopic debridement was successful in 15 patients (group 1) and unsuccessful in six patients (group 2), who required a thoracotomy and decortication. Group 1 had a shorter mean duration of preoperative symptoms (13 versus 27 days; p=0.03), a shorter median duration of preoperative hospitalization (6 versus 18 days; p=0.04), and a lower incidence of previous thoracostomy drainage (4/15 versus 5/6; p=0.05). CONCLUSIONS: The technique of VATD is most likely to be successful when used within one week of diagnosis of a loculated parapneumonic empyema. A prospective trial comparing VATD with intrapleural fibrinolytic agents for the initial treatment of pediatric empyema is needed.

Adolescent↗
PubMed1998

Sympathetic skin response and patient satisfaction on long-term follow-up after thoracoscopic sympathectomy for hyperhidrosis.

OBJECTIVES: To determine effect of sympathectomy for hyperhidrosis on sympathetic skin response (SSR) during long-term follow-up. Patient satisfaction was assessed and surgical complications noted. DESIGN: Prospective, Open, Non-randomised study. MATERIALS AND METHODS: Patients who had undergone bilateral thoracoscopic sympathectomy for hyperhidrosis underwent postoperative assessment of SSRs. A 15 mA stimulus was applied over the median nerve contralateral to the sympathectomy and evoked electrodermal activity was recorded from the sympathectomised palm using a Dantec Counterpoint Mk 2. Patient satisfaction with surgery was assessed by questionnaire and visual analogue score (0-1.0). RESULTS: Of 26 patients, 21 were female. Mean (range) age was 23 (9-36) years. Mean (range) follow up was 39 (4-138) months. 12% of cases had residual or recurrent symptoms. Median (range) patient satisfaction was 0.83 (0.06-1.0). In 7/52 palms recurrent SSRs were not detected. Repeated measures analysis of variance found amplitude of SSR to be of low significance with respect to time since surgery (F = 0.48; p = 0.49) and incidence of compensatory sweating (F = 2.38; p = 0.14). CONCLUSION: Thoracoscopic sympathectomy for hyperhidrosis is an effective procedure. Following sympathectomy SSRs are not permanently abolished, but return of SSRs does not correspond with symptom recurrence. As such, SSRs are a poor tool for objective assessment of long-term outcome following sympathectomy.

Adolescent↗
PubMedDate not supplied

A decision analysis of the optimal initial approach to achalasia: laparoscopic Heller myotomy with partial fundoplication, thoracoscopic Heller myotomy, pneumatic dilatation, or botulinum toxin injection.

In the absence of randomized controlled trials that directly compare all of the modern methods of managing achalasia, decision analysis may help determine the optimal treatment strategy. Four strategies for the initial management of achalasia were compared using the following decision model: (1) laparoscopic Heller myotomy and partial fundoplication; (2) pneumatic dilatation; (3) botulinum toxin injection; and (4) thoracoscopic Heller myotomy. Probabilities of clinical events and utilities of health states were estimated using review of the medical literature and patient interviews. A recursive decision tree (Markov model) was used to simulate all the important outcomes of each initial treatment option, allowing for complications, relapses over time, and transitions between strategies when appropriate. After 10 years, laparoscopic Heller myotomy with partial fundoplication was associated with the longest quality-adjusted survival (quality-adjusted life years [QALY] = 7.41). The difference between this strategy and either pneumatic dilatation or botulinum toxin injection was small. Thoracoscopic Heller myotomy was associated with the poorest quality-adjusted survival (QALY = 7.15). Pneumatic dilatation was the favored strategy when the effectiveness of laparoscopic surgery at relieving dysphagia was less than 89.7%, the operative mortality risk was greater than 0.7%, or the probability of reflux after pneumatic dilatation was less than 19%. In a decision model, laparoscopic Heller myotomy with partial fundoplication is at least as effective as endoscopic approaches for managing achalasia symptoms. However, the differences are small enough that patient preferences and local expertise should be taken into consideration when tailoring a treatment plan for an individual patient.

Botulinum Toxins↗