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PubMed2004

[Current diagnostic approach to pleural effusion].

Pleural effusion is a common pneumologic and interdisciplinary problem. Transudate/exsudate discrimination of the pleural fluid by thoracentesis remains the diagnostic basic algorithm. Regardless of a number of new markers, classical LIGHT's criteria comprising the pleural fluid protein- and LDH-values (or their serum ratio respectively) reveal the highest potency with an overall accuracy of 95 %. Expansion to cholesterol-determination (triplet test) may be helpful to identify transudates in indeterminate cases. The need for further local diagnostic evaluation is then usually restricted to exudates. Bacterial pleurisy, malignant and tuberculous effusion are the principal differential diagnoses. With the use of a variety of conventional biochemical, cytologic, immunologic and microbiologic investigations, thoracentesis will allow- or substantially narrow-diagnosis of exudates in about 70 %, with novel cell biological markers in some conditions up to 90 %. In bacterial pleurisy thoracentesis provides information directly relevant to management in terms of local interventions. It also constitutes a platform for more invasive imaging- or endoscopy-guided investigations with a focus on medical thoracoscopy (pleuroscopy). Blind needle biopsy is diagnostic in a range of 40 - 70 % both in malignancy and inflammatory disease, thoracoscopy may clarify exudative conditions in about 95 %. Thus malignancy may be specifically diagnosed in 97 % of cases, tuberculous effusion in virtually 100 %. The value of thoracoscopy is augmented by interventional options including complete evacuation of the pleural cavity, eventually followed by talc pleurodesis ("poudrage") in recurrent effusions or adhesiolysis, irrigation and fibrinolysis protocols in certain inflammatory conditions. These combined features as accomplished in local anesthesia on a remarkably high safety level characterise medical thoracoscopy as a gold standard tool for the management of pleural disease even in comparison to more elaborate surgical procedures.

Biopsy, Needle↗
PubMed1998

Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram's needle biopsy.

STUDY OBJECTIVES: Recently, pulmonologists have performed thoracoscopy under local anesthesia using rigid thoracoscopes or flexible bronchoscopes. The latter allow greater access within the pleural cavity but are difficult to manipulate. The Olympus LTF semiflexible fiberoptic thoracoscope combines features of both instruments, having a solid body and a flexible terminal section. In the first study with this instrument, we evaluated ease of use and compared diagnostic yield with closed needle biopsy. PATIENTS: Twenty-four patients with pleural effusion were investigated. SETTING: Scottish University Hospital. DESIGN: Thoracoscopy was performed in the bronchoscopy suite after premedication with atropine and papaveretum. Following a standard Abram's needle biopsy, the LTF thoracoscope was inserted through a flexible introducer (Olympus Optical Co Ltd; Tokyo, Japan). The pleura was inspected and biopsy specimens were taken of suspicious areas. RESULTS: The final diagnosis was malignant pleural effusion in 16 of 24 patients. Ten of 16 were positive by Abram's biopsy, giving a sensitivity of 62%. Thirteen of 16 were positive by fiberoptic thoracoscopy, giving an improved sensitivity of 81%. The LTF thoracoscope was easy to use for pulmonologists experienced in rigid thoracoscopy and flexible bronchoscopy. Excellent views of the pleura were obtained from a single entry point. The procedure was well tolerated and no complications were encountered. CONCLUSION: The LTF thoracoscope allows excellent pleural access but a larger biopsy channel (currently 2 mm) might increase the accuracy of diagnosis.

Adjuvants, Anesthesia↗
PubMed1989

Survival time of patients with pleural metastatic carcinoma predicted by glucose and pH studies.

STUDY OBJECTIVE: To determine the survival time of patients with pleural metastatic carcinoma diagnosed by thoracoscopy, as related to the pleural glucose and pH levels, and to the extension of pleural neoplastic lesions. DESIGN: Cohort analytic prospective study. Follow-up of the patients from diagnostic thoracoscopy to death (range: one to 29 months). SETTING: Referral Pneumology Service at a Tertiary Care Center. PATIENTS: Consecutive sample of 50 patients with pleural metastatic carcinoma diagnosed by thoracoscopy. Three patients were lost in the follow-up. INTERVENTIONS: Talc pleurodesis was performed after diagnosis and with the same technique in every case. MEASUREMENTS AND RESULTS: In all the cases, the extension of the tumorous lesions was determined by thoracoscopy (classified on a scale from 0 to 9) and the survival time was studied from the time that thoracoscopic diagnosis was made. On the same or the previous day as the exploration, blood and pleural fluid glucose levels as well as arterial and pleural pH and gas tensions were determined.

Follow-Up Studies↗
PubMedDate not supplied

Pediatric empyema--an algorithm for early thoracoscopic intervention.

INTRODUCTION: The management of pediatric empyema remains controversial. We contend that early thoracoscopic intervention results in shorter hospital stays, decreased morbidity, and superior outcomes. We propose an algorithm using early image-guided thoracoscopy as an effective treatment for pediatric empyema. METHODS: Consecutive pediatric empyemas treated from November 1997 to April 2001 using a prospective management algorithm were reviewed. Demographic data, days to diagnosis, days to surgery, length of stay, chest tube days, complications, and follow-up were recorded. RESULTS: Twenty-two children with 24 empyemas were treated using this algorithm. Their mean age was 49 months. Mean days to diagnosis was 11 and from diagnosis to surgery was 3. Imaging included chest radiography (CXR) in all, ultrasound in 17 (77%), and computed tomography (CT) scan in 13 (59%). One thoracoscopy was converted to a mini-thoracotomy because of difficulty with ventilation. Chest tube removal averaged 3 days with an average length of stay of 13 days. One patient required a second thoracoscopy for recurrent empyema, and 1 patient developed a contralateral empyema. No other complications or deaths occurred. Follow-up in 19 of 22 (86%) children at 5 months revealed no recurrences or mortality. CONCLUSION: This treatment algorithm, using early image-guided thoracoscopy, is a safe and effective means of managing pediatric empyema, while shortening hospital stay and avoiding the morbidity of thoracotomy.

Algorithms↗
PubMed2001

Value of digital exploration for diagnosing injuries to the left side of the diaphragm caused by stab wounds.

HYPOTHESIS: The digital exploration of stab wounds in the left thoracoabdominal region allows the early diagnosis of diaphragmatic lesions. DESIGN: Diagnostic test study. The digital exploration of the diaphragm was compared with laparotomy (the gold standard) and thoracoscopy. SETTING: The study setting was the Hospital Universitario San Vicente de Paúl (Medellín, Colombia). This is a referral trauma center for the general community. PATIENTS: The study included 82 consecutive patients who were admitted to our institution during a 12-month period with injuries caused by stab wounds to the left thoracoabdominal region and who did not have indications for immediate surgery. Digital exploration of the wound was performed by the attending surgeon in the emergency department. If a lesion of the diaphragm was identified, a laparotomy was performed; if no diaphragmatic lesion was found, a diagnostic left thoracoscopy and/or laparotomy was performed. Results of the laparotomy (n = 63) or thoracoscopy (n = 19) were used as the standard of reference for the determination of sensitivity, specificity, and predictive values of digital exploration. INTERVENTION: The integrity of the diaphragm was determined by digital exploration through the stab wound. MAIN OUTCOME MEASURES: Sensitivity, specificity, predictive value, and likelihood ratio were calculated. RESULTS: For the detection of diaphragmatic lesions, digital exploration demonstrated a sensitivity of 96%, a specificity of 83.3%, a positive predictive value of 91%, and a negative predictive value of 93.7%. CONCLUSION: Digital exploration is a reliable method for the detection of injuries to the left side of the diaphragm caused by stab wounds.

Adolescent↗
PubMed1996

Reduced inflammatory response in minimal invasive surgery of pneumothorax.

OBJECTIVE: To elucidate whether thoracoscopy for surgical therapy of pneumothorax leads to a reduction of inflammatory responses in comparison with standard thoracotomy. DESIGN: A prospective randomized study PATIENTS: Eleven patients (9 men and 2 women; median age, 28 years; range, 21-44 years) were treated by thoracotomy; 10 patients (9 men and 1 woman; median age, 26 years; range, 21-28 years) were managed thoracoscopically. The plasma concentrations of the following were determined: polymorphonuclear granulocyte elastase and C-reactive protein as inflammatory parameters and prostanoids (prostacyclin, thromboxane A2, prostaglandin F2 alpha, prostaglandin M, and prostaglandin E2) as vasoactive parameters. Blood sampling was performed perioperatively and on day 3 after surgery. RESULTS: The thoracoscopy group revealed a shorter hospital stay (5 vs 7 days; P < .05) and a significantly reduced need for intravenous pain medication within 48 hours (1 vs 3 requirements; P < .01) vs the thoracotomy group. The release of inflammatory (C-reactive protein, P < .01) and vasoactive (prostacyclin and thromboxane A2, P < .01) mediators was less during thoracoscopy compared with standard thoracotomy. CONCLUSIONS: The thoracoscopic procedure is less invasive when performing wedge resection of apical blebs. With intracavitary management being equivalent to the conventional technique, the curtailed morbidity after thoracoscopic surgery is considered to be related to the minimal trauma associated with the access to lung tissue and the reduced handling of lung tissue.

Adult↗
PubMed1996

Animal model for thoracoscopic laser ablation of emphysematous pulmonary bullae.

BACKGROUND AND OBJECTIVE: Thoracoscopic laser techniques have been described for treatment of pulmonary bullae. Clinical application of this procedure has proliferated despite limited data regarding efficacy or optimal techniques. The objective of this study was to develop an animal model for investigating laser treatment of bullous lung disease. STUDY DESIGN/MATERIALS AND METHODS: Sixty-two New Zealand White rabbits (3-5 kg) were injected intravenously with 0.35 cc sterile-filtered Sephadex G-100 beads (1 g/100 cc suspension). Three hours later, rabbits were anesthetized, intubated, and 10 cc 0.7% heat-treated or 1% untreated carrageenan solution was instilled endotracheally into a catheter wedged in a mainstem bronchus. RESULTS: Bullae formed over 4-6 weeks in 33% of the animals treated with 0.7% heat-treated carrageenan, and 90% of animals receiving 1% untreated carrageenan (P < 0.005) as demonstrated by serial thoracoscopy. Thoracoscopy was performed at 6-8 weeks using 5 mm trocars under general anesthesia and mechanical ventilatory support. Animals developed pulmonary bullae ranging in size from 0.5 to 2 cm. Bullae were ablated under thoracoscopic visualization using a CO2 laser with a 4 mm OD rigid probe and short focal length in a defocused mode, or an Nd:YAG laser with a 0.4 mm diameter flexible fiberoptic probe. Animals recovered quickly following thoracoscopy. CONCLUSION: We have successfully developed an animal model for thoracoscopic laser ablation of emphysematous pulmonary bullae. This animal model should be useful in investigating treatment of bullous lung disease in humans.

Animals↗
PubMedDate not supplied

Thorascopic staging of stomal recurrence.

BACKGROUND: Squamous cell carcinoma of the low cervical area may be secondary to stomal recurrence following laryngectomy, low cervical esophageal disease, or peritracheal metastasis. Most often patients with disease in this area have already received both surgery and radiotherapy. Prior to Sisson's description of the trans-sternal radical neck dissection or mediastinal dissection the management and prognosis was uniformly poor. Since then, a number of authors have reported their experience with mediastinal dissection. Survival remains poor but palliation has been acceptable. Unfortunately, resectability of the disease cannot often be determined prior to the actual surgical procedure. A number of patients are explored only to have the procedure terminated. Thoracoscopy is a procedure that involves insertion of two or three trocars into the right thoracic cavity with collapse of the right lung. A form of endoscopic surgery, it permits visualization and dissection of the important structures of the mediastinum. Tracheal, esophageal, and great vessel invasion by tumor can be evaluated. METHODS: Prospectively, all patients initially seen with stomal recurrence from 1991 to 1994 were evaluated. CT scans, MRIs as well as thoracoscopy were performed when indicated. RESULTS: One patient required conversion to a minithoracotomy involving a 7-cm chest incision. The patient was found to have unresectable disease with tumor involving the great vessels of the mediastinum. A second patient was found to have unresectable disease with tumor encasing the subclavian artery. The third patient was found to have no mediastinum involvement. The patient with no mediastinum involvement underwent a stomal resection with mediastinal dissection. Reconstruction with a pectoralis major myogenous flap was performed. The patient has remained disease free to date. The remaining two patients were judged to have unresectable disease and were offered palliative treatment. Both of these patients died of the disease within 6 months. CONCLUSIONS: Thoracoscopy provides important information in judging the surgical resectability of patients with stomal recurrence. This procedure has not been previously described in the otolaryngologic literature. We provide some suggestions for its use in the evaluation of the mediastinal extent of disease.

Aged↗
PubMed1994

Contribution of videothoracoscopy to the management of the cancer patient.

BACKGROUND: Videothoracoscopy has rapidly become a popular procedure, but its technical feasibility has been emphasized without critically evaluating its role in the management of thoracic disease. To assess the value of videothoracoscopy in the diagnosis and staging of the cancer patient and to determine if it has added to our previous standard approach of thoracoscopy performed with a mediastinoscope without video, we established a prospective database when we initiated videothoracoscopy in January 1992. METHODS: Patients were offered videothoracoscopy as an alternative to thoracotomy only if other standard approaches (e.g., needle biopsy, mediastinoscopy) were inadequate to diagnose or stage cancer or to restage patients after therapy. Parameters entered and analyzed in a prospective database were patient name; age; sex; past history; indications for videothoracoscopy; procedure type; surgical technique; whether conversion to thoracotomy was necessary, and if so, why; complications; and pathology. A complete case list of thoracoscopies performed in 1991 before videothoracoscopy was available provided historical comparison. RESULTS: From January 1 to December 31, 1991, 82 patients underwent thoracoscopy using a mediastinoscope for diagnosis and therapy of pleural disease. From January 1 to July 31, 1992, 160 patients (male:female = 81:79; mean age 56 years) had videothoracoscopy; 72 of 160 patients (44%) had procedures that previously would have required thoracotomy: 69 lung wedge resections, one pericardial window, one pleurectomy, one mediastinal node sampling. No major resectional procedures (e.g., lobectomy, esophagectomy) were performed by videothoracoscopy. Twenty-two percent of all patients (35 of 160), and 23% of wedge resection patients (16 of 69) required conversion to thoracotomy because videothoracoscopy was inadequate for diagnosis or staging. Reasons for conversion (multiple reasons in five patients) included further resection required in 23 patients; inability to evaluate lesion in 11; adhesions in five; and inability to tolerate one lung ventilation in two. The chest tube was in place postoperatively for a mean of 2.3 days. Thirty-day postoperative complications included ventilation for > 48 h in one patient; prolonged air leak in one; pneumonia in one; arrhythmia in one; and death from progressive disease in two. CONCLUSIONS: Although the role of videothoracoscopy in the treatment of primary thoracic malignancies and pulmonary metastases is still undefined, this early experience indicates that videothoracoscopy often enhances the ability to diagnose and stage patients by obviating thoracotomy.

Adult↗
PubMed1998

Thoracoscopic techniques for the management of intrathoracic metastases. Results.

BACKGROUND: The authors reviewed a series of 74 patients with cancer metastatic to the chest cavity undergoing thoracoscopic procedures. Indications, feasibility, and outcome of thoracoscopy were analyzed. METHODS: Perioperative and survival data on patients undergoing 89 operative thoracoscopic procedures between January 1991 and August 1993 were retrieved from a prospective database. These procedures included pulmonary wedge resection (n = 61), lobectomy (n = 2), pleurodesis (n = 11), pleural biopsy (n = 7), decortication (n = 1), and mediastinal mass resection (n = 2). In 13 cases, combined procedures were performed. Five thoracoscopies were converted to open thoracotomies to facilitate resection. RESULTS: Thoracoscopic pulmonary resections were performed for either diagnostic (n = 45) or curative (n = 18) intent. Diagnostic thoracoscopies were done for lesions in which less invasive biopsy attempts had failed to provide tissue, or that were considered too small for successful percutaneous biopsy. Thoracoscopic diagnostic accuracy was 100%. For the 18 patients undergoing potentially curative resection, mean follow-up is 15.4 months. Sixteen of these patients are currently alive, and eight are free of disease. Five complications related to the procedure included persistent air leak (n = 2), atrial fibrillation (n = 2), and urinary retention (n = 1). Overall hospital stay for thoracoscopic lung resection was 4.6 +/- 2.2 days, for converted open thoracotomy 6.8 +/- 1.9 days, and for patients undergoing pleurodesis 8.9 +/- 5.3 days. Mean chest tube duration after thoracoscopic resection was 2.6 +/- 1.6 days. CONCLUSIONS: Thoracoscopic procedures are safe, well tolerated, and useful for diagnosis and treatment of selected patients with suitable intrathoracic metastatic disease.

Adult↗
PubMed1996

Videothoracoscopy an effective method for evaluating and managing thoracic trauma patients.

BACKGROUND: The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients. METHODS: The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2). RESULTS: The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient. CONCLUSIONS: Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.

Adolescent↗
PubMed1992

Videothoracoscopy: improved technique and expanded indications.

Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favorable results. Application of this technology to our practice of thoracoscopy is the basis of this report. Videothoracoscopy has been performed in 39 patients for the following indications: chronic pleural effusion, interstitial lung disease, mediastinal lymphadenopathy in lung cancer, persistent air leak after decortication, mediastinal mass, recurrent spontaneous pneumothorax, hydropneumothorax with persistent air leak, and pleural-based mass. The technique we employ includes lateral decubitus positioning and double-lumen endotracheal intubation with ipsilateral lung collapse. The videoscope, retractors, and instruments are introduced through separate 10-mm incisions. Percutaneous manipulation of instruments and the videoscope is guided by images produced on television screens without dissection, and if resection is performed, the incision is enlarged to allow specimen retrieval. Procedures performed using this technique include pleural biopsy, partial pleurectomy, lysis of adhesions, lung biopsies, staging lymph node biopsy, lung nodule biopsy, pleural-based mass resection, and mediastinal mass biopsy and resection. This videoendoscopic technique greatly improves visualization of thoracic anatomy, facilitating thoracoscopy and enhancing exploration of the chest. It is preferred over conventional thoracoscopy and, in some patients, reduces the magnitude of operation by avoiding thoracotomy.

Adult↗
PubMed1993

Initial experience with video-assisted thoracoscopic lobectomy.

In the past 2 years, the development of video-assisted thoracic surgery (VATS) has allowed thoracoscopy to rapidly evolve from a primarily diagnostic tool to a therapeutic tool with potentially useful applications. As with laparoscopy, the initial enthusiasm for VATS must be tempered by the reality of technical inadequacies, complications, and results that have yet to withstand careful scientific scrutiny. The purpose of this study was to determine the technical feasibility of a VATS lobectomy. Forty-four patients with primary bronchogenic carcinoma were evaluated and accepted as potential candidates for VATS lobectomy. After complete preoperative staging, these patients were in clinical stage I. All patients had normal arterial blood gases and adequate pulmonary function (forced expiratory volume in 1 second > 1.5 L) to tolerate a lobectomy. At the time of operation, 3 patients were found to have N2 disease and were excluded from the study. In 35 of the remaining 41 patients, a successful VATS lobectomy was accomplished through two thoracoscopy ports and a non-rib-spreading 6- to 8-cm "access" thoracotomy. There were no major intraoperative complications that necessitated conversion to an open thoracotomy. Mean operative time was 153 +/- 26 minutes. All 35 patients recovered uneventfully with a mean hospital stay of 5.7 +/- 1.6 days. A VATS lobectomy is technically feasible using our approach and is potentially safe. However, major advances in thoracoscopy imaging and instrumentation are necessary before this procedure will have the potential for widespread acceptance. Also, the advantages of VATS lobectomy over accepted surgical techniques will have to be carefully documented in randomized trials.

Carcinoma, Bronchogenic↗
PubMed1993

The history of thoracoscopic surgery.

The necessity for thoracoscopy became apparent with the adhesions that limited the success of Forlanini's introduction in 1882 of artificial pneumothorax in the treatment of pulmonary tuberculosis. The first thoracoscopy, using a modified cystoscope, was performed by H. C. Jacobaeus, a professor of medicine, not surgery, in Stockholm, publishing in 1910. Thoracoscopy and division of adhesions (intrapleural pneumonolysis) then spread all over the world, with reports of series of 1,000 or more cases in spite of a significant incidence of complications. Its use declined rapidly after the introduction of streptomycin in 1945, becoming then confined to relatively minor diagnostic procedures except in a few European centers. The advent of video-assisted thoracoscopes and the development of ancillary instruments has allowed a new explosion of thoracoscopic surgery. Surgeons, in whose hands the procedure now rests, should nevertheless be aware of the five unacceptable thoracoscopic disasters--wrong side, kebab lung, "clotted hemothorax," artificial lunchothorax, and aorto-pleuro-cutaneous fistula.

England↗
PubMed1993

Thoracoscopic lymph node staging for esophageal cancer.

Thoracoscopy allows evaluation of the mediastinum and assessment of the local spread of malignancy. Adjuvant therapy trials have shown some increased survival for esophageal cancer although morbidity is high. Preoperative staging may allow appropriate allocation of adjuvant therapy. Patients with esophageal cancer underwent computed tomographic scan, magnetic resonance imaging, and endoesophageal ultrasonography. Thoracoscopic staging was performed through the left chest with biopsy of American Thoracic Society level 5 and 6 and 8 and 9 lymph nodes. Resection at a separate sitting with complete intraoperative lymph node sampling was done. Fourteen patients underwent thoracoscopic lymph node staging. One procedure could not be completed because of adhesions. Of the 13 patients undergoing successful staging, all had correct thoracic lymph node staging confirmed at surgical exploration. Two patients with adenocarcinoma of the distal third/gastroesophageal junction were found at laparotomy to have positive celiac lymph nodes. Two patients who had lymph nodes positive at computed tomographic scan and magnetic resonance imaging were found to have negative lymph nodes at thoracoscopy and subsequent resection. Two patients were found to have pulmonary metastasis at thoracoscopy. Lymph node stage in esophageal carcinoma is an important prognostic indicator. Thoracoscopic lymph node staging provides accurate pre-resection staging information.

Adenocarcinoma↗
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↗
PubMed2006

Fluoroscopy-assisted thoracoscopic resection of pulmonary nodules after computed tomography--guided bronchoscopic metallic coil marking.

OBJECTIVE: To localize small and deeply situated pulmonary nodules during thoracoscopy with roentgenographic fluoroscopy, we developed a marking procedure that uses a metallic coil. METHODS: Nine patients underwent video-assisted thoracoscopic surgery for the removal of 11 pulmonary lesions. Fluoroscopy-assisted thoracoscopic surgery after computed tomography-guided bronchoscopic metallic coil marking was performed with an ultrathin bronchoscope, with simulation by means of virtual bronchoscopy. During thoracoscopy, a C-arm-shaped roentgenographic fluoroscope was used to detect the radiopaque nodules. RESULTS: The marking procedure took 15 to 60 minutes from insertion to removal of the bronchoscope. There were no complications from the marking, and all 11 nodules were easily localized by means of thoracoscopy. The metallic coil showed the nodules on the fluoroscopic monitor, which aided in nodule manipulation. Nodules were completely resected under thoracoscopic guidance, except in one case in which a minithoracotomy was performed at an early stage of the trial. The pathologic diagnosis was primary adenocarcinoma in 9 patients, pulmonary metastasis from colon cancer in 1 patient, and pulmonary lymph node in 1 patient. Two cases of bronchioloalveolar adenocarcinoma with an invasive component and a well-differentiated adenocarcinoma were converted to open thoracotomy to perform curative lobectomy. CONCLUSIONS: In this pilot study computed tomography-guided transbronchial metallic coil marking with an ultrathin bronchoscope with virtual bronchoscopic simulation might be a useful method for the fluoroscopy-assisted thoracoscopic resection of pulmonary nodules.

Adult↗
PubMed2000

Thoracoscopic esophageal mobilization for pharyngolaryngoesophagectomy.

BACKGROUND: Pharyngolaryngoesophagectomy (PLE) for hypopharyngeal cancers and tumors of the cervical esophagus is a procedure of significant morbidity and mortality. Conventional esophageal mobilization is performed with the transhiatal dissection technique. Thoracoscopic esophageal mobilization is tested as an alternative to determine whether surgical outcome can be improved. METHODS: From 1994 to 1998, thoracoscopic mobilization was carried out in 30 consecutive patients who underwent PLE (PLE-TS). This was compared to a historical cohort of 30 patients who had PLE with transhiatal mobilization (PLE-TH). RESULTS: In PLE-TS, thoracoscopic esophageal mobilization was successful in 28 patients (93%). Median blood loss was 700 mL (range, 164 to 3,000 mL) compared to 1,000 mL (range, 400 to 2,200 mL) in group PLE-TH, p = 0.21. Thoracoscopy time was 90 minutes (range, 60 to 180 minutes). Total operating time were 392 minutes (range, 180 to 570 minutes) and 300 minutes (range, 150 to 550 minutes) in PLE-TS and PLE-TH, respectively (p = 0.03). Major pulmonary complications occurred in 7 (23%) and 8 (27%) patients in PLE-TS and PLE-TH, respectively (p = 0.77). Cardiac complications occurred in 7 (23%) and 5 (17%) patients in PLE-TS and PLE-TH, respectively (p = 0.52). Thirty-day mortality rates were 3.3% and 10% (p = 0.6) and hospital mortality rates were 13% and 17%, (p = 1.0). CONCLUSIONS: Thoracoscopy was safe and feasible. Morbidity and mortality after PLE was not significantly reduced. The theoretical advantage offered by thoracoscopy may be offset by the lengthened time of one-lung anesthesia.

Adult↗