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The video shows six different established thoracoscopic interventions besides the treatment of spontaneous pneumothorax. Adhesiolysis (1) is demonstrated in a patient with malignant pleural effusion, followed by palliative pleurodesis by talkage (2). Resections of benign extra- (3) and intrapulmonary (4) tumors are shown as well as endoscopic pericardial fenestration (5) and thoracic sympathectomy (6).
PURPOSE: The aim of the study was to reduce investigation time, radiation dose, and contrast material when performing spiral-CT of the thorax. METHODS: 50 patients with different clinical diagnoses underwent spiral-CT of the thorax with double table feed and 45 ml contrast material (lopentol) were injected. Density measurements were performed as follows: main pulmonary artery without contrast injection, carotid artery, subclavian artery, ascending and descending aorta, aortic arch, main pulmonary artery and thoracic aorta after contrast injection. RESULTS: In comparison to the density of the main pulmonary artery without contrast injection there was an increase of density of 134 HU. 45 ml of the contrast agent were sufficient in all cases for delineation of the mediastinal vessels. Investigation time was 16-18 s and all patients were able to hold their breath during this time, so no artifacts were seen. Radiation dose was cut in half. CONCLUSION: Spiral-CT with double table feed enables investigations of the thorax in less than 20s. 45 ml of a contrast agent are sufficient for performing this examination. There are no essential diagnostic deficits with this technique.
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The presently known methods of thoracoscopic surgery are a symbiosis of traditional thoracic surgery and of new endoscopic techniques. The traditional methods determine the proceeding on the organ, the innovative ones the measure to reach it. The challenge is to carry out traditional procedures on the lung by means of the new technique without loss of quality. The accomplishments of simple thoracoscopic operations on lung, pleura, and mediastinum are mostly determined. In cases of major thoracic surgical interventions new resection techniques, not yet proven on lung vessels and bronchi are increasingly undertaken. This means an innovation in two respects and is therefore difficult to evaluate. In our clinic thoracoscopic surgical techniques are orientated towards preserving the established methods on the organ via new accesses with recently developed endoscopic instruments. After having treated over 400 patients, we are now able to show that the presented thoracoscopic methods offer an advanced and safe way towards modern thoracic surgery. However, it is too early to present standardized surgical techniques of thoracoscopic surgery.
During the period March 3, 1992 to September 30, 1993 36 video-assisted thoracoscopic operations were performed at the Surgical Department of the University of Cologne. In 12 cases wedge resection of peripheral pulmonary nodules were carried out. Two of the patients underwent video-assisted thoracoscopic lobectomy of the left lower lobe due to peripheral primary bronchogenic carcinoma. In 6 cases biopsy of the lung or pleura was undertaken. Further indications were partial pleurectomy and resection of blebs (n = 12). Pleural effusion was drained under thoracoscopic vision twice. No intraoperative complications occurred. Two patients proceeded to thoracotomy after persistence of pneumothorax following thoracoscopic pleurectomy. The postoperative course of the remaining patients was uneventful and was especially characterized by the reduction in pain and disability. In accordance to the experience of other authors we believe that thoracoscopic surgery is a method with a promising future. Further investigations have to evaluate indications, different techniques, and long term results.
The rapid evolution or rather revolution of minimally invasive surgical techniques is stimulating new technical and clinical innovations. Quality control is of great importance in new areas of technical development where standards do not yet exist. By recording detailed documentation of patient data, indications, operative procedures and initial follow-up we can compare this new technology with the gold standard therapy. This documentation system for thoracoscopic interventions was developed together with the Swiss Group of Laparoscopic and Thoracoscopic Surgeons. This pilot project of 85 consecutive thoracoscopic interventions will demonstrate the acceptability, clinical application and ease with which data can be analyzed. Operative techniques are described in detail: 20 diagnostic interventions with biopsy, 19 apical parietal pleurectomies (+/- resections of bullous lung tissue), 10 therapeutic lung tissue resections, 19 palliative pleurodesis, 5 treatments of pleural empyema, 1 mediastinal tumor resection, 1 esophagectomy, 4 thoracic sympathectomies plus 6 other procedures. Data entry is efficient with mean total time of 10 min for each record. All of the data are entered into a computer database. The possibilities for interpreting and combining this data are presented. The operative techniques can easily be related with history, indications, anesthesia, complications and results. First evaluation of thoracoscopic efficiency is possible. In addition, a detailed analysis of intra- and postoperative complications and of the hospital course can be performed.
Recent developments in molecular biology have made it possible to detect molecules such as mRNA and DNA in situ. In this report we focused on non-radioactive in situ hybridization histochemistry using the alkaline phosphatase-labeled oligodeoxynucleotide probe, which has recently been developed. We report the advantages of this method and some applications such as semiquantitative analysis and simultaneous demonstration of two mRNAs in a single section. In addition, vasoactive intestinal polypeptide (VIP) receptor mRNA was demonstrated in the lung as an application of in situ hybridization histochemistry in the field of thoracic diseases. We compared the localized of VIP mRNA-positive cells between normal animals and an animal mode of asthma.
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Video-assisted thoracoscopy was used to remove a bronchogenic cyst in a 6-year-old boy and a foregut duplication cyst in a 2-year-old girl. Access ports were placed along the site of a proposed thoracotomy incision and chest tube exit site. Thoracoscopic excision was uneventful, and each child left the hospital on the second postoperative day. Video-assisted thoracoscopy has a role in the evaluation and the definitive treatment of intrathoracic masses in children.
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The authors report the main clinical and radiographic aspects of a circumscribed myositis ossificans in a 5 year old child located in the thoracic wall, near the sternum, stimulating a malignant tumor. CT scan was more contributive than MRI, both for diagnosis and survey, because it shows better the progressive peripheral calcification typical of the lesion.
Magnetic resonance (MR) is the imaging method used to assess primary and secondary inflammatory lesions of the chest wall. Five patients with inflammatory lesions of the anterior chest wall were submitted to MR examinations in order to define the role of this method in both identification and assessment of the extent of tissue involvement. In all the examined patients MR Imaging accurately showed the involved muscle groups and the presence/absence of mediastinitis. MR Imaging easily detected sternal and clavicular osteomyelitis; in one patient only MR failed to detect osteomyelitis of the first rib. The accurate assessment of soft tissue infections enabled us to select the most suitable surgical therapy to reduce esthetic damage. Two cases were restudied after chest wall reconstruction by means of rotated pectoral flaps. In the 2 patients in whom the differential diagnosis between inflammatory lesion and recurrent tumor could not be made by means of MR Imaging, CT-guided needle biopsy was performed.
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Preoperative imaging of the tracheobronchial tree should focus on identifying the location, severity, and extent of tracheal narrowing, as well as possible causes of extrinsic compression. Plain film radiography and esophagography can be supplemented with CT or MR imaging for the evaluation of mediastinal masses or vascular abnormalities impinging on the airway. Surgical planning for the removal of intrathoracic tumors or cysts requires a detailed evaluation of the location and extent of the lesion, identification of encasement or compression of vital structures, and intraspinal extension to determine resectability and the need for neurosurgical consultation. Precise preoperative histologic diagnosis in most patients is not essential for surgical planning. Although the anatomic information provided by CT and MR imaging is comparable, MR offers the advantage of multiple imaging planes and allows the identification of intraspinal involvement of posterior mediastinal tumors or neuroenteric cysts without the use of intrathecal contrast agents. Conversely, MR imaging has little role in the assessment of pulmonary parenchymal abnormalities. These are best imaged with radiography and CT. Plain film radiography and contrast esophagography are often sufficient for the identification and delineation of postoperative complications in the chest. Complex air or fluid collections, however, may require further study with CT or ultrasonography for better characterization.
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The continuity of cervicomediastinal fascial planes provides the anatomic basis for cervical mediastinoscopy and its derivatives. There are two such planes, both accessible through a single small neck incision: the retrovascular paratracheal plane (for standard cervical mediastinoscopy) and the prevascular retrosternal plane (the zone of extended mediastinal exploration). This article describes the evolution, technique, indications, applications, and complications of cervical mediastinoscopy in the diagnosis and therapy of thoracic diseases.