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PubMed1994

Needle localization of peripheral lung nodules for video-assisted thoracoscopic surgery.

Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules. To localize small peripheral lung nodules that may not be visible or palpable by the surgeon, we have placed a Kopans hook wire percutaneously into the lung as a guide. The indications for localization included previous nondiagnostic percutaneous needle aspiration biopsy (PNAB) (n = 4), nodules too small for PNAB (n = 2), nodules inaccessible to PNAB (n = 3), and planned resection of a known peripheral tumor less than 1 cm (n = 1). The localization procedure was performed with computed tomographic guidance in all patients. The nodules ranged in size from 2 to 15 mm and were located immediately subpleural to 2-cm deep the pleura. A 20-gauge Greene biopsy needle was used as an introducer for a 35-cm-long Kopans hook wire. Patients were sent directly to the operating room in a dependent position. All ten nodules were successfully resected, including hamartoma (n = 1), carcinoid tumors (n = 2), granulomas (n = 3), adenocarcinoma (n = 1), fibrosis (n = 1), benign metastasizing leiomyoma (n = 1), and lymphoma (n = 1). In two patients, the wire slipped out of the lung. Small focal pneumothoraces developed in five patients. There were no major complications. This procedure can safely and effectively localize nonvisible or nonpalpable pulmonary nodules for thoracoscopic surgery for diagnostic purposes or for resection of small peripheral tumors in patients who cannot tolerate a lobectomy or pneumonectomy.

Aged↗
PubMed1994

Successful management of recurrent pneumothorax in cystic fibrosis by localized apical thoracoscopic talc poudrage.

Thoracoscopic talc poudrage of the entire pleural surface constitutes successful treatment of recurrent pneumothorax in cystic fibrosis (CF); however, subsequent lung transplantation is seriously jeopardized due to the development of extensive pleural adhesions. We describe a 27-year-old patient with CF with recurrent right-sided pneumothorax, refractory to chest tube drainage and to chemical (tetracycline) pleurodesis, who was successfully treated with a localized, apical thoracoscopic talc poudrage, thereby preserving the possibility of subsequent lung transplantation.

Adult↗
PubMed1994

Thoracoscopic findings in spontaneous pneumothorax in AIDS.

Six patients with the acquired immunodeficiency syndrome (AIDS) who suffered eight spontaneous pneumothoraces between January 1990 and January 1993 underwent videothoracoscopy. The predominant macroscopic findings, found in four patients on five occasions, were white-yellow nodules dispersed throughout the lung surface. In addition, in one patient, these lesions were associated with multiple small apical bullae and, in another, a large reddish nodule with several smaller white satellite nodules was noted on the parietal pleura. Methenamine silver stain of biopsy samples of both the visceral and parietal nodules in these patients showed the presence of Pneumocystis carinii. May-Grunwald-Giemsa stain of brushing samples of visceral lesions revealed P-carinii in two patients. In one of these patients, previously performed bronchoalveolar lavage (BAL) had not yielded P-carinii. On two occasions, the thoracoscopic findings were unremarkable, although in one of these patients, computed tomography (CT) had shown a large thick-walled cyst near the left hilum and BAL revealed P-carinii. Talc poudrage through the thoracoscopic cannula followed by chest tube drainage was performed in all patients and was successful in treating three of five with proved P-carinii pneumonia-related pneumothorax. The etiology of pneumothorax in AIDS and the diagnostic and therapeutic utility of videothoracoscopy in these patients are discussed.

AIDS-Related Opportunistic Infections↗
PubMed1996

Thoracoscopic lobectomy for benign diseases.

The few reports in the literature on thoracoscopic anatomic lung resections were almost exclusively for early primary lung cancers. We report our combined experience on video-assisted thoracoscopic (VAT) lobectomy for benign diseases from two major hospitals in Hong Kong over a 20-month period. From August 1993 to March 1995, 66 VAT lobectomies were performed; of this number, 10 cases (15%) were for benign diseases (5 tuberculosis, 2 organized pneumonia, 1 bronchiectasis, 1 sclerosing hemangioma, 1 infected bronchogenic cyst). There was no mortality or incidence of intraoperative complications. Postoperative complications occurred in one patient with tuberculosis and consisted of persistent air leak and subsequent wound infection. There were no long-term complications after a mean follow-up of 11 months. The mean duration of chest tube drainage was 6.7 days and that of hospital stay was 9.8 days. These results were not statistically different from those achieved in VAT lobectomies performed for malignant tumors (5.0 days for drainage and 6.8 days for hospital stay) despite the fact that hilar dissection was sometimes more difficult in the former because of inflammatory changes. We conclude that VAT lobectomy for benign diseases is technically feasible even though its role in thoracic surgery remains to be defined.

Adult↗
PubMed1996

Thoracoscopic management of malignant pleural effusions.

Malignant pleural effusion is a common condition and often presents a challenge for treatment. We report our experience from a single institution with the use of video-assisted thoracoscopic surgery (VATS) in the management of malignant effusions. From September 1992 to April 1995, 69 patients (31 men, 38 women; age range, 38 to 76 years) underwent diagnosis and/or treatment of malignant effusions; these included 46 pleural biopsies, 34 talc insufflations, and 16 limited decortications. There was no mortality and there were no intraoperative complications. Postoperative complications occurred in seven patients (10%). Specific histologic diagnoses were obtained in all but 6 patients (87%). Malignant effusion was confirmed in 25 of 46 cases (54%). Thoracoscopic talc insufflation with or without additional decortication was successful in 32 of 34 cases (94%) in controlling recurrence of effusion after a mean follow-up of 6 months among the survivors (22 patients died during the follow-up period without effusion reaccumulation). We conclude that VATS not only provides an accurate diagnosis but also allows effective therapeutic procedures to be performed for malignant effusions that are associated with an acceptable morbidity.

Adult↗
PubMed1997

Dyspnea response following bilateral thoracoscopic staple lung volume reduction surgery.

PURPOSE: Lung volume reduction surgery (LVRS) has shown promise for treating patients with severe emphysema in recent clinical trials. However, response following surgery is difficult to assess due to frequent discrepancies between subjective and objective outcomes. We evaluated the relationship between improvement in dyspnea and pulmonary function response in 145 consecutive patients with inhomogeneous emphysema enrolled in a bilateral thoracoscopic lung volume reduction protocol in order to assess predictors of improved dyspnea outcome and correlation of subjective and objective improvement measures. MATERIALS AND METHODS: Baseline complete pulmonary function testing, spirometry, gas exchange, plethysmography, gas dilution lung volumes, along with resting dyspnea index determinations were performed preoperatively, and repeated short term (mean, 33 days; n=129) and long term (>6 months; mean, 276 days; n=84) following surgery. RESULTS: Improvement in FEV1 percent predicted was significantly associated with improvement in dyspnea scores, though considerable variability exists (r=0.04, p<0.01, short term; r=0.4, p=0.1, long term). In this preselected patient group, those with the extreme degrees of hyperinflation may have less improvement in dyspnea following LVRS than those with milder preoperative hyperinflation. Greater improvement in dyspnea short term and long term was seen in patients with lower presenting residual volume/total lung capacity ratios (r=0.4, p=0.02, short term; r=0.4, p<0.05, long term). CONCLUSIONS: Bilateral thoracoscopic staple LVRS results in significant objective and subjective improvement in patients with severe emphysema and hyperinflation. There was considerable variability between improvement in dyspnea and improvement in spirometry, and preoperative predictors of response may differ between these outcome variables. Further studies are needed to define the long-term implications of these findings.

Aged↗
PubMed1998

Thoracoscopic talc poudrage in malignant pleural effusions: effective pleurodesis despite low pleural pH.

STUDY OBJECTIVE: To determine the effectiveness of pleurodesis by thoracoscopic talc poudrage (TTP) in patients with low pH malignant pleural effusions. DESIGN: Review of prospectively collected data on all thoracoscopic procedures performed from 1982 to 1996. PATIENTS AND SETTING: Twenty-five members in a prepaid, closed-panel health maintenance organization, whose malignant pleural effusion pH was < or = 7.30. INTERVENTIONS: Pleural fluid pH was measured prior to diagnostic and therapeutic, single puncture, rigid thoracoscopy, under local anesthesia, in an operating room. MEASUREMENTS AND RESULTS: Success of pleurodesis was determined with serial radiographs at 10 days, 30 days, and frequent intervals until death or up to 1 year following the procedure. Failure was indicated by evidence of recurrent fluid or persistence of a space between the visceral and parietal pleura. Morbidity of the procedure, days of chest tube drainage, and days of hospitalization were recorded concurrently during hospitalization and outpatient follow-up. Fifty of the 76 patients found to have a pleural pH measurement had a pleural pH >7.30, averaging 7.37 (7.31 to 7.55). The other 26 patients (34%) with pH < or = 7.30 (low pH) are the subjects of this study, of whom 25 were evaluable. Pleurodesis was successful in 22 of 25 (88%), although 4 died prior to 30 days. The three failures all had trapped lung. Chest tube drainage averaged 3.2+/-1.3 days, which approximated the time of hospitalization (3.3+/-1.1 days). There were no thoracoscopy-related deaths; significant morbidity occurred only in one patient with trapped lung, who had prolonged chest tube drainage before and after TTP, and eventually developed empyema. CONCLUSIONS: TTP is an effective pleurodesis technique in malignant pleural effusions, even when the pleural pH is low. The short hospital stay and high success rate make this approach a good choice in palliating symptomatic malignant pleural effusions.

Adult↗
PubMed1998

Intraoperative brachytherapy following thoracoscopic wedge resection of stage I lung cancer.

STUDY OBJECTIVES: Local recurrence is high when sublobar resection is chosen as primary management of stage I non-small cell lung carcinoma. Postoperative external-beam radiotherapy may reduce this local recurrence problem. A technique of intraoperative brachyradiotherapy following thoracoscopic wedge resection is described as an alternative to adjuvant external-beam radiotherapy for high-risk patients who are not candidates for pulmonary lobectomy. PATIENTS: Fourteen patients with significant impairment in cardiopulmonary function having small peripheral solitary pulmonary nodules underwent video-assisted thoracoscopic (VATS) wedge resection and were found to have non-small cell cancer. Surgical margins were pathologically clear and mediastinal nodes were benign-stage I (T1NO). INTERVENTIONS: A custom polyglyconate mesh (Vicryl) containing 125I seeds was applied to pulmonary resection margins following wedge resection of peripheral lung cancers. A total dose of 100 to 120 Gy at 1 cm was applied to the target area. RESULTS: All patients had histologically clear surgical margins. Postoperative dosimetry confirmed adequate resection margin coverage. There was neither operative mortality nor morbidity related to the VATS wedge resection or the brachytherapy implants. Implants did not migrate, and there were no cases of significant radiation pneumonitis or local recurrence at mean follow-up of 7 months (range, 2 to 12 months). CONCLUSIONS: Intraoperative brachytherapy appears to be a safe and efficient alternative to external-beam radiation therapy when adjuvant radiotherapy is considered following therapeutic wedge resection of stage I (T1NO) lung cancers. The impact on local recurrence, disease-free interval, and survival will require additional follow-up.

Brachytherapy↗
PubMed2000

Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series.

STUDY OBJECTIVES: Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema. DESIGN: We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema. RESULTS: Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy. CONCLUSIONS: Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.

Adolescent↗
PubMed2004

Video-assisted thoracoscopic surgery using single-lumen endotracheal tube anesthesia.

BACKGROUND: Most general thoracic surgeons use double-lumen endotracheal tube (DLET) anesthesia for all video-assisted thoracoscopic surgery (VATS). We evaluated a single-lumen endotracheal tube (SLET) for VATS for drainage of pleural effusions and pleural biopsies. METHODS: A consecutive series of patients with recurrent pleural effusions underwent VATS using an SLET and only one incision. Operations were accomplished via one 2-cm incision using a 5-mm rigid thoracoscope and mediastinoscopic biopsy forceps for directed pleural biopsies. A working area was accomplished with low tidal volumes. RESULTS: There were 376 patients (191 women). The indications for VATS were a nondiagnosed or benign pleural effusion in 294 patients, and a malignant effusion in 82 patients. Two hundred eight patients underwent biopsy of the parietal pleura, and mean operative time was 17 min. Adequate visibility was obtained in all. When compared to preoperative cytology, VATS was more sensitive (45% compared to 99%, p < 0.001), had a higher negative predictive value (56% compared to 99%, p < 0.001), and was more accurate (67% compared to 99%, p < 0.001). Forty-seven percent of patients with a history of cancer had false-negative preoperative cytology results. Complications occurred in seven patients (2%), and there were three operative deaths (none related to the operative procedure). CONCLUSION: VATS using SLET and only one incision is possible, and it affords excellent visualization of the pleural space, allowing pleural biopsies and talc insufflation. It avoids the risk, time, and cost of a DLET. It is significantly more sensitive and accurate than preoperative cytology, and it should be considered as the diagnostic and therapeutic procedure of choice in patients with recurrent pleural effusions.

Adult↗
PubMed2005

Clinical efficacy and safety of thoracoscopic talc pleurodesis in malignant pleural effusions.

STUDY OBJECTIVES: In patients with disseminated neoplastic disease, recurrent pleural effusion is frequently observed. The purpose of this study was to determine the long-term efficacy and safety of pleurodesis by thoracoscopic talc poudrage (TTP) in malignant pleural effusions (MPEs). METHODS: We report a consecutive series of 102 patients (45 women, 57 men; 20 to 83 years of age) who underwent medical thoracoscopy and TTP for recurrent MPE between 1999 and 2001. Thoracoscopy was performed utilizing local anesthesia and IV sedation (medical thoracoscopy). For pleurodesis, an average of 8 g of sterile talc powder was used. One hundred eighty-day follow-up was completed for all patients, and outcome measures included time to recurrence of the effusion and survival. Efficacy was judged by clinical examination, chest radiograph, and/or thoracic ultrasound examination. Procedure-related complications were documented. RESULTS: The most common primary neoplasms were lung cancer (n = 48), breast cancer (n = 16), and malignant pleural mesothelioma (n = 10). Twenty-eight patients had other types of tumors, including renal cell carcinoma, ovarian carcinoma, GI tumors, prostate, malignant lymphoma, and unknown primary cancer. At the end of the primary observation period of 180 days, 38 of 46 surviving patients (82.6%) had a successful pleurodesis. Type of primary neoplasm had no significant influence on success rate. The 30-day mortality rate was 16.7% (n = 17). Survival curves after 180 days showed significant differences, with best survival in mesothelioma and shortest life expectancy in lung cancer (p = 0.005). Adverse effects included empyema in one case and malignant invasion of the scar. No episode of talc-induced ARDS was observed. CONCLUSION: Thoracoscopic talc pleurodesis is a safe and effective method to stop recurrent MPEs. Lasting pleural symphysis is obtained.

Adult↗
PubMed2005

Thoracoscopic lung biopsy is a safe procedure in diagnosing usual interstitial pneumonia.

OBJECTIVES: To evaluate the effect of lung biopsy on the survival of patients when histopathologic confirmation of usual interstitial pneumonia (UIP) is needed. BACKGROUND: Idiopathic pulmonary fibrosis is a distinct clinical entity with histopathologic features of UIP. Surgical biopsy is needed when clinical and radiologic findings are not typical. The safety of lung biopsy is a matter of debate, and the results of short-term mortality (< 30 days) after biopsy are variable. METHODS: Seventy-six patients with UIP, including 34 patients who underwent video-assisted thoracoscopic surgery (VATS) biopsy and 42 patients who underwent open-lung biopsy, were included in this retrospective study. All biopsies were reevaluated for UIP histopathology. Clinical data such as age at the time of biopsy, type of biopsy, preoperative pulmonary function, major postoperative complications, date and cause of death, and survival time after the biopsy were gathered. Median survival was used to compare the survival between different groups, and cumulative survival was estimated using Kaplan-Meyer method. RESULTS: Thoracoscopic biopsy was safe for diagnosing UIP, with no short-term mortality. In contrast, open-lung biopsy was followed by four deaths (5.3%) within 1 month after the procedure. All fatal cases were accompanied by a histopathologic pattern of diffuse alveolar damage. Age of the patient at the time of biopsy was a significant predicting factor for survival. Patients < 50 years old lived 181 months (range, 119 to 242 months), and patients > 50 years old lived 75 months (range, 55 to 95 months). CONCLUSIONS: VATS biopsy is a safe procedure in diagnosing UIP.

Biopsy↗
PubMed1999

Thoracoscopic correction and placement of anterior instrumentation for scoliotic deformity. Case report.

Correction of rigid scoliotic deformities involving the thoracic spine has required that a thoracotomy be performed to obtain anterior release to mobilize the deformity, as well as placement of corrective spinal instrumentation either via a separate posterior or anterior thoracic approach. To the best of the author's knowledge, this is the first published report of a case in which anterior correction of a deformity was achieved endoscopically. A 27-year-old man presented with a rigid 85 degrees thoracic kyphoscoliotic deformity that had developed over several years. He had previously undergone a C7-T12 laminectomy to decompress the spinal cord from a lipoma. Using thoracoscopic techniques, the author performed an anterior release and interbody fusion. Endoscopically, an anterior screw/rod system applied from T-5 to T-9 corrected the deformity to 55 degrees . There were no surgery-related complications. At follow-up examiniation 1.5 years after surgery, the patient had developed a solid fusion and the correction was maintained at an angle of 58 degrees . It is feasible to use thoracoscopic techniques to perform an anterior release and to apply anterior corrective spinal instrumentation to treat thoracic scoliotic deformities, thereby avoiding the need for an open posterior approach in which instrumentation is placed.

Journal Article↗
PubMed2000

Treatment of thoracic disc herniation: evolution toward the minimally invasive thoracoscopic technique.

Thoracic disc herniation has always carried with it the potential for serious adverse neurological consequences if not treated appropriately. The authors review the historical evolution of treatment for thoracic disc herniation from the early surgical series using dorsal approaches (which were known to involve a significant risk of paraplegia) to later surgical series in which lateral and then ventral approaches to the disc were increasingly emphasized, with significant improvement in patient outcome. The evolution of minimally invasive thoracoscopic techniques is discussed, together with the results of several surgical series demonstrating significant reductions in morbidity compared with more traditional methods. The technique of thoracoscopic discectomy is presented in detail.

Animals↗
PubMed1998

Thoracoscopic microsurgical excision of herniated thoracic discs.

OBJECT: The authors began using thoracoscopy to treat pathological conditions of the spine in 1992. In this study they delineate their clinical experience in which this procedure was used to resect herniated thoracic discs. METHODS: Fifty-five patients underwent thoracoscopy for the resection of herniated thoracic discs. Thirty-six patients presented with myelopathies and 19 with incapacitating thoracic radicular pain. Forty-three patients underwent a single-level, 11 a two-level, and one a three-level discectomy. The mean operative time for thoracoscopic microdiscectomy was 3 hours and 25 minutes (range 80-542 minutes) and the mean blood loss was 327 ml (range 124-1500 ml). Compared with thoracotomy, which was performed in 18 patients, thoracoscopy was associated with a mean of 1 hour less operative time and less than one-half of the blood loss, duration of chest tube drainage, usage of pain medication, and length of hospitalization. Compared with costotransversectomy, which was performed in 15 patients, thoracoscopy permitted more complete resection of calcified and midline thoracic discs because it provided a direct view of the entire anterior surface of the dura. Thoracotomy was associated with a significantly greater incidence of prolonged, disabling intercostal neuralgia compared with the mild transient episodes of intercostal neuralgia associated with thoracoscopy (50% compared with 16%). Thoracotomy also was associated with a significantly higher incidence of postoperative atelectasis and pulmonary dysfunction than thoracoscopy (33% compared with 7%). Clinical and neurological outcomes were excellent (mean follow-up period 15 months). Among the 36 myelopathic patients, 22 completely recovered neurologically; five improved functionally but had some residual myelopathic symptoms; and nine stabilized. Among the 19 patients with isolated thoracic radiculopathies, 15 recovered completely and four improved moderately; no patient had worsened radicular pain. CONCLUSIONS: Thoracoscopic microdiscectomy is a reliable surgical technique that can be performed safely with excellent clinical and neurological results.

Adult↗
PubMed1998

Thoracoscopic apical pleurectomy for persisting or recurring pneumothorax.

Regardless of its origin, the treatment of persisting or recurring spontaneous pneumothorax (SP) is classically surgical. To assess the contribution of thoracoscopy in the management of SP 100 consecutive patients with persistent or recurrent pneumothorax were treated at our unit by endoscopic procedure between 1992 and 1997 to obtain permanent pleurodesis and to treat the lung lesion responsible for the leak. There were 90 men and 10 women ranging in age from 16 to 60 years (mean age 28+/-12 years). The technique includes electrocoagulation of pleural blebs and thoracoscopic apical pleurectomy. All patients were subjected to physical examination and plain x-ray at 1 and 3 months and 1 year postoperatively. After completion of the procedure, air leaks disappeared in 90 cases, while 5 cases air leak ceased 5 to 7 days postoperatively. The remaining 5 cases were converted to an open procedure. The mean length of follow-up was 3 years. No patient required transfusion and there were no operative deaths. No recurrence of pneumothorax occurred and no major complications encountered. Video-assisted thoracoscopic pleurectomy for the treatment of pneumothorax is concluded to be that safe and efficacious. It shortens the hospital stay, requires less amount of postoperative narcotic analgesia.

Adolescent↗
PubMed2004

Thoracoscopic sympathectomy in the management of vasomotor disturbances and complex regional pain syndrome of the hand.

Complex regional pain syndrome, vasospastic disorders, and hyperhidrosis are chronic and debilitating upper extremity problems. Twenty-nine consecutive patients treated with thoracoscopic sympathectomy are presented. Diagnoses included complex regional pain syndrome, hyperhidrosis, Buerger's disease, Raynaud's disease, and peripheral vascular disease. All patients with hyperhidrosis had complete symptom resolution. Patients with Buerger's and Raynaud's disease had excellent/good results. Six patients with complex regional pain syndrome had excellent or good relief; the remaining six patients had varying degrees of recurrence. A statistically significant association was noted between duration of complex regional pain syndrome prior to sympathectomy and outcome. Thoracoscopic sympathectomy is an effective treatment for hyperhidrosis and vasospastic disorders. Although the results for complex regional pain syndrome are not uniformly excellent, this technique offers promise in the treatment of this difficult problem.

Adolescent↗
PubMed2005

Video assisted thoracoscopic surgery for spinal conditions.

Video-assisted thoracoscopic surgery (VATS) has become an alternative treatment tool for a variety of spinal conditions in the last two decades. This endoscopic or "keyhole" approach minimizes the chest wall morbidity related to the traditional thoracotomy. The current indications for VATS are the same as in any open anterior spinal surgery. This article reviews the outcomes of VATS treatments in thoracic disc diseases, fractures, tumors and vertebral osteomyelitis. In addition, we have described our "learning curve" and surgical techniques using video-assisted thoracoscopic spinal releases and instrumentation in the treatment of 50 patients with adolescent idiopathic scoliosis.

Anesthesia↗