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PubMed2000

A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for diagnosis and treatment of peripheral pulmonary nodules. However, thoracoscopy has limits in the detection of small nodules, below the pleural surface, deep in the lung parenchyma, which cannot be seen as much as palpated. Methods to localize such lesions, including the methylene blue injection or the introduction of a hooked-wire under the radiological vision, have some advantages but a lot of limitations. We are developing a new technique for the detection of pulmonary nodules smaller than 2 cm, deep in the lung parenchyma. METHODS: The technique consisted of a intra-lesional injection of 0.3 ml of solution of 99m Tc-labelled human serum albumin microspheres (5-10 MBq) under the CT-scan guide, 2 h before surgery. During thoracoscopy a 11 mm diameter-collimated probe connected to a gamma ray detector (Scinti Probe MR 100 - Pol. hi.tech., Aquila - Italy), is introduced by a 11.5 mm trocar and the pleural surface of the suspected area was scanned. A hot-spot indicated the presence of the injected nodule and as a consequence, the area to be resected. RESULTS: from June 1997 to June 1999 we treated 39 patients with small pulmonary nodules. The patients were 27 men and 12 women with a mean age of 60.8 years (range: 13-80). In 19 cases the anamnesis was positive for synchronous or metachronous malignant neoplasm. The mean surgical procedure length was 50 min (range 20-100 min). In all the cases the nodule was resected and the resection margins were pathologically free of tumour. The mean post-operative hospital stay was 3 days (range 2-6 days). Histological examination showed 21 benign lesions and 18 malignant lesions (seven metastases and 11 primary lung cancers). Nine pts with primary lung carcinoma underwent a completion lobectomy by open surgery. CONCLUSIONS: Radiolocalization by gamma-probe allows the detection and exeresis of small nodules in a easy and safe way. Future and predictable advances in radio-marked monoclonal antibodies, as well as in the development of endoscopic beta-detector probe, will offer a more effective method for detection of primary and metastatic tumours, targets of thoracoscopic resections.

Adolescent↗
PubMed2004

[Video-assisted thoracoscopic surgery in 3 cases of adult cystic adenomatoid malformation].

Congenital cystic adenomatoid malformation involving the lung is a rare hamartomatous condition that is usually diagnosed in the neonatal period. The presentation of this malformation in older patients is exceptional and usually manifests in a series of recurrent lung infections affecting a single lobe or segment. The treatment of choice is complete surgical exeresis. This report of 3 cases of late presentation focuses on the surgical approach used and the unusual manifestation of recurrent spontaneous pneumothoraces in 1 patient. The patients were females aged 15, 16, and 25 years with histories of various respiratory diseases (extrinsic asthma, recurrent pneumonias, and pneumothoraces). The patients were referred to us for surgery with suspected diagnoses that were different from the final diagnoses in all cases. All underwent diagnostic video-assisted thoracoscopy to explore the affected hemothorax, and definitive treatment was possible during the procedure for 2 patients (a lobectomy and an atypical segmentectomy) by video-assisted surgery. The third patient underwent lobectomy by lateral thoracotomy after exploratory video-assisted thoracoscopy. Short- and long-term outcomes were excellent for all 3 patients.

Adolescent↗
PubMed2000

The effect of lung biopsy on lung function in diffuse lung disease.

The aim of this study was to investigate the effect on lung function of lung biopsy used in the diagnosis of diffuse lung disease carried out by an open procedure or by video-assisted thoracoscopy. One hundred and sixteen patients with diffuse lung disease who attended the Royal Brompton Hospital were studied retrospectively. Thirty five patients underwent open lung biopsy, and 33 video-assisted thoracoscopic biopsy and 48 had their diagnosis made without biopsy. All patients underwent lung function tests before and after surgery, or at an interval of 3-6 months in those who did not undergo biopsy. No significant differences were found in changes in lung function between those who had and had not undergone biopsy, and the proportions of patients whose lung function improved or deteriorated were similar. Lung biopsy by an open procedure or by video-assisted thoracoscopy did not differ in its effects on lung function. The results for older patients, those with severe disease and those with fibrosing alveolitis were the same as for the whole group. Open lung biopsy for the diagnosis of diffuse lung disease does not deleteriously affect lung function whether carried out by an open or a minimally invasive procedure.

Adult↗
PubMed1998

Controlled prospective study of positron emission tomography using the glucose analogue [18f]fluorodeoxyglucose in the evaluation of pulmonary nodules.

BACKGROUND: Positron emission tomography (PET) is a new imaging technique which, by measuring focal metabolic activities, can make a qualitative statement (benign or malignant) about a tumour. PET has been described in many studies to provide a high diagnostic accuracy for the evaluation of pulmonary coin lesions. However, these studies were not always supported by histological confirmation of the results. In a controlled prospective study, it was investigated whether the diagnostic accuracy of PET is sufficiently high to allow omission of diagnostic thoracotomy or thoracoscopy in the case of a negative finding. METHODS: A PET scan was carried out before operation using [18F]fluorodeoxyglucose (FDG) in 50 patients with pulmonary coin lesions (diameter 30 mm or less). All of these lesions were completely removed thoracoscopically or by a formal thoracotomy and were examined histologically. Using the histology results, the diagnostic accuracy of the PET procedure with regard to a benign or malignant diagnosis was evaluated and compared with that of computed tomography (CT). Results From a total of 54 coin lesions (four of the 50 patients had two lesions) there were 31 malignant (19 primary bronchial carcinomas, 12 metastases) and 23 benign diagnoses. With the PET procedure 28 of 31 malignant and 19 of 23 benign lesions were classified correctly (sensitivity 90 per cent, specificity 83 per cent). False negatives included two bronchial carcinomas and one metastasis. CT had a sensitivity of 100 per cent and specificity of 52 per cent. CONCLUSION: FDG PET cannot generally be considered as a replacement for diagnostic thoracoscopy or thoracotomy at the present time. However, by combining FDG PET with radiological follow-up, clinical applications may evolve in patients at low risk for a malignant tumour or at high risk for surgical complications.

Adenocarcinoma↗
PubMed1994

Current Issues in the Staging of Esophageal Cancer.

Staging technology and the 1983 international staging system for esophageal cancer have changed. The 1988 system is based on depth of wall penetration and regional lymph node involvement; it abandons the previous criteria of tumor length and degree of obstruction. The clinical reasoning behind this change is reviewed. New staging technology includes chest computed tomography (CT), magnetic resonance imaging (MRI), tranesophageal ultrasound (EUS), and invasive surgical staging. Overall accuracy of CT to predict depth of penetration is 80% to 85%. CT accuracy of regional lymph node status is less than 69%, but it is 90% accurate in the detection of distant metastases. MRI is comparable. EUS is 71% to 98% accurate in predicting depth of tumor invasion. Although highly sensitive (85% to 95%), the accuracy of EUS in predicting the status of lymph nodes is adversely affected by low specificity (50% to 60%), reducing its overall accuracy of node prediction to 70% to 88%. EUS may fail to assess intra-abdominal disease in 21% to 36% of patients secondary to esophageal obstruction. Regional nodes on both sides of the diaphragm can be assessed by laparoscopy combined with thoracoscopy. Thoracoscopy and laparoscopy have a greater than 92% accuracy in staging regional nodes. Such information is indispensable for the design of treatment fields. Combinations of these new technologies may provide improved preresectional staging.

Journal Article↗
PubMed2005

[The management of spontaneous pneumothorax].

The optimum management of spontaneous pneumothorax (SPTX) includes medical and surgical approaches but remains somewhat controversial due to inconclusive data background both in the treatment of the acute episode and preventive strategies. Current consensus recommendations suggest, that small and asymptomatic pneumothoraces can be managed conservatively by observation. Large and symptomatic pneumothoraces will respond to simple aspiration or small size catheter (< 16 F) insertion in about (2)/ (3) of cases. Otherwise, and in secondary SPTX, particularly in the elderly patient, large size (> 20 F) chest drainage, optimally combined with thoracoscopy (pleuroscopy), is the treatment of choice allowing success rates up to 96 %. Preventive strategies are indicated after the first recurrence and when predisposing pleuropulmonary lesions as in secondary SPTX are evident. With efficacy as a primary endpoint, currently available data do not provide clear evidence-based preference criteria between medical thoracoscopic talc pleurodesis and surgical strategies (usually VATS-based partial pleurectomy +/- parenchymal resection). Therefore selection of the appropriate procedure remains influenced by expert opinion. However simple talc poudrage under medical thoracoscopy has been shown to be highly effective, safe and cheap at a cost level virtually not exceeding that of large size chest drainage.

Catheterization↗
PubMed2006

[Success and complication rate of CT-guided marking of pulmonary nodules with coil wires for video-assisted thoracoscopic surgery (VATS)].

PURPOSE: To assess the success and complication rate of the CT-guided marking of pulmonary nodules for video-assisted thoracoscopic surgery (VATS). MATERIALS AND METHODS: Pulmonary nodules (mean diameter 9 +/- 5 mm, mean pleural distance 7 +/- 5 mm) were marked with a coil wire in 30 patients (20 males, mean age 57.6 +/- 15.5 years, 22 patients with a history of malignancy). The intended coil-nodule distance was < or = 10 mm. RESULTS: 81 % of nodules were not visible by thoracoscopy. The technical success rate of CT-guided marking was 86.7 %. The projected nodule-coil distance was achieved in 90 % of cases. The procedure had to be changed from thoracoscopy to thoracotomy in 4 patients due to coil wire marking problems: 2 x coil displacement, 1 x coil-nodule distance > 10 mm, unfavorable direction of wire. Histology was determined in all patients (70 % malignant, 30 % benign). Complications requiring therapy were not observed. CONCLUSIONS: The CT-guided marking of pulmonary nodules is a precondition for VATS if the nodule does not involve the visceral pleura in the majority of cases. The success rate is high with a low complication rate.

Adult↗
PubMed2002

Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery.

OBJECTIVE: Widespread clinical use of helical computed tomography has improved the detection rate for small peripheral pulmonary nodules. As a result, use of thoracoscopic surgery to confirm the diagnosis of small peripheral pulmonary nodules has become more important than ever before. However, if small peripheral pulmonary nodules are too small or located too deeply to detect thoracoscopically, it is necessary to mark the small peripheral pulmonary nodules preoperatively. The purpose of this study was to determine indications for preoperative hookwire marking in thoracoscopic resection of small peripheral pulmonary nodules. METHODS: A total of 120 patients underwent thoracoscopic pulmonary resection in our institute from 1999 to 2001. Small peripheral pulmonary nodules were marked preoperatively in 61 of these patients by means of percutaneous placement of a hookwire under computed tomographic guidance. The hookwire-marked small peripheral pulmonary nodules either were smaller than 10 mm or were located more than 10 mm below the pleural surface. RESULTS: Although 9 of the hookwire-marked small peripheral pulmonary nodules were easily identified during thoracoscopy, the other 52 small peripheral pulmonary nodules could not have been identified during thoracoscopy without the hookwire marking. Of the 59 small peripheral pulmonary nodules that were not hookwire marked, 7 required conversion to thoracotomy to locate the nodules. Small peripheral pulmonary nodules from both groups were examined and assigned to either an undetectable or detectable group. Discriminant function analysis indicated that a linear function (ie, depth = 0.836 x size - 2.811) could be used to differentiate between undetectable and detectable small peripheral pulmonary nodules, and preoperative hookwire marking for small peripheral pulmonary nodules should be considered for nodules in the region above those. CONCLUSION: The results suggest that this formula might serve as an indication for preoperative marking of small peripheral pulmonary nodules in thoracoscopic resection.

Female↗
PubMed2002

Methods of lung separation.

In the last few years, video assisted thoracoscopy, which allows a wide variety of diagnostic and therapeutic procedures, has been introduced into clinical practice. A growing enthusiasm for minimally invasive surgical approaches and improvements in video endoscopic surgical equipment has resulted in the widespread use of this technique. Most video assisted thoracoscopy procedures require a well-collapsed lung and should only be included in the absolute indication for one-lung ventilation. Following placement of a double lumen tube, it is the standard of care to check the tube is positioned correctly using fiberoptic bronchoscopy. The role of the right-sided double lumen tube is discussed in detail in this review. Finally, there are alternatives to the use of the double-lumen tube to achieve lung separation, such as the Univent tube or an independent bronchial blocker. In many situations the double-lumen tube cannot be inserted, due to a difficult airway or at the conclusion of the procedure changing the double lumen tube to a single lumen tube may result in loss of control over the airway. In such situations, it is essential for the anesthesiologists to be familiar with the existing alternatives to the double-lumen tube.

Journal Article↗
PubMed1997

Malignant pericardial effusion.

The clinical symptoms of cardiac tamponade associated with malignancy are reviewed, and the importance of these symptoms in relationship to treatment decisions are discussed. The clinical findings of tamponade and the echocardiographic findings have been correlated. The approach to treatment of cardiac tamponade has been summarized. The various surgical techniques, including pericardial window formation, subxyphoid drainage, and thoracoscopy and video-assisted thoracoscopy, are discussed and the relative benefits of the various procedures have been presented. Results of the less invasive percutaneous balloon pericardiostomy procedure have also been reviewed, and updates of recent small series have been included. Medical management of malignant pericardial effusion with small-bore tube drainage followed by sclerosis has been reviewed, and the results of recent series reporting the effectiveness of various sclerosing agents, including tetracycline, doxycycline, and bleomycin, have been compared.

Cardiac Tamponade↗
PubMed2002

Video-assisted thoracoscopic surgery for thoracic disc disease: Classification and outcome study of 100 consecutive cases with a 2-year minimum follow-up period.

STUDY DESIGN: Prospectively collected data from regular clinical follow-up evaluations were tabulated, analyzed, reviewed using a patient self-reported questionnaire. OBJECTIVE: To develop a classification system and present the long-term functional outcome of video-assisted thorascopic surgery for refractory thoracic disc disease. SUMMARY OF BACKGROUND DATA: Recent studies have found an 11.1% to 14.5% prevalence of thoracic disc herniations. Surgical approaches have included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, transthoracic-transpleural thoracotomy, and thoracoscopy. Recent reports have documented encouraging early results with video-assisted thorascopic surgery for thoracic disc herniations. Comparisons between thoracoscopy and open thoracotomy have demonstrated improvement in postoperative pain and morbidity with the use of endoscopic techniques. METHODS: This study included 100 consecutive patients (45 women and 55 men) with an average follow-up evaluation of 4 years (range, 2-6 years). The average age of the patients was 42 years (range, 22-76 years). The average duration of symptoms was 26 months (range, 6-96 months), and 18 patients had undergone prior spine surgery. Patients were graded as follows according to the presenting symptoms (Table 1): Grade 1 (pure axial; n = 28), Grade 2 (pure radicular; n = 5), Grade 3A (axial and thoracic radicular; n = 38), Grade 3B (axial with lower leg pain; n = 19), Grade 4 (myelopathic; n = 8), or Grade 5 (paralytic = 2). RESULTS: A total of 117 discs were excised in 100 patients. Of the 40 patients who underwent fusion, 27 had autologous rib struts and 13 had threaded fusion. The mean operative time was 173 minutes, blood loss 259 mL, average ICU stay less than 1 day, and average hospital stay 4 days. Minor complications occurred in 21 patients, all of which resolved with no untoward effect. No patient's neurologic status worsened. Four patients underwent a secondary fusion, and a pseudarthrosis developed in one patient. Clinical success was defined objectively as an improvement in Oswestry score of 20% or more at 2 years and at final follow-up assessment, as compared with the preoperative Oswestry score. Overall, objective clinical success was observed at 2 years in 73% of the patients, and at final follow-up assessment in 70% of patients. The average percentage of improvement in Oswestry scores was most marked in Grade 4 patients (myelopathy; 60%), followed by Grade 3A patients (axial and thoracic radicular pain; 37%), Grade 3B patients (axial with leg pain; 28%), and Grade 1 patients (pure axial; 24%). The Oswestry disability score (Table 2) and back pain visual analog score (Table 3) also were significantly improved (P < 0.05) at 2 years and at final follow-up assessment in these patients. In the Grade 2 patients, those pure thoracic radicular pain, Oswestry scores initially improved significantly up to 1 year (P < 0.05). At 2 years, no significant improvement could be shown, and four of the five Grade 2 patients reported increased axial pain as their main symptom at the final follow-up assessment. Significant improvement also was seen in patients with no prior spine surgery and patients with preoperative Oswestry disability scores greater than 50. Of the 68 patients who responded to the final questionnaire, 12 rated the procedure as excellent, 37 as good, 11 as fair, and 8 as poor. Also, 57 (83.8%) of these 68 patients were satisfied and indicated they would recommend the surgery. Of the 36 patients at the final follow up assessment who had severe disability, 34 (94%) were satisfied, as compared with 23 of the 32 patients (72%) who had presented with milder disability. CONCLUSIONS: The clinical classification system helps in differentiating different presentations of thoracic disc disease and their final outcome. Video-assisted thorascopic surgery appears to be a safe and efficacious method for the treatment of refractory symptomatic thoracic disc herniations. The current data suggest that the procedure has an acceptable long-term outcome, with an 84% overall subjective patient satisfaction rate, and with objective long-term clinical success achieved in 70% of patients.

Adult↗
PubMed2004

Pulmonary involvement in Crohn's disease report of a case and review of the literature.

Crohn's disease (CD) is a granulomatous systemic disorder of unknown etiology. Obvious pulmonary involvement is exceptional in patients with CD. We report a case of a 38-year-old man who suffered from CD for more than 14 years and was treated with oral steroids for more than 10 years. Surgical excision of parts of the ileum was performed for life-threatening ileal bleeding caused by CD. After acute tapering of oral steroids, pulmonary symptoms and radiologic abnormalities were noted. Lung biopsy through thoracoscopy was performed and revealed signs of chronic inflammation with multiple subepithelial noncaseating and epithelioid granulomas on pathologic examination. Intravenous steroids were required in the initial management of life-threatening pulmonary dysfunction after diagnostic thoracoscopy and led to marked improvement. Tuberculocidal therapy was performed until all microbiological cultures were negative. Oral steroid dosage had slowly been tapered over 1 month. He was discharged with clinical and radiologic improvements. After 36 months, the patient's condition is stable on continued treatment with prednisolone and mesalazine.

Adult↗
PubMed2005

Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary?

STUDY DESIGN: A retrospective review of adolescents with main thoracic scoliotic curves surgically treated with either anterior release and posterior fusion or posterior fusion only. OBJECTIVES: To compare the radiographic and clinical outcomes of two surgical treatments: anterior-posterior spinal fusion (APSF) versus posterior spinal fusion (PSF) alone in patients with large 70 degrees to 100 degrees thoracic adolescent idiopathic scoliosis (AIS) curves. SUMMARY OF BACKGROUND DATA: Surgical treatment of thoracic AIS curves between 70 degrees and 100 degrees often consists of anterior and posterior fusion to improve the coronal correction and fusion rate, with the anterior release and fusion performed through either an open thoracotomy or by video-assisted thoracoscopy. METHODS: All patients (n = 84) with main thoracic major AIS curves between 70 degrees and 100 degrees who underwent spinal fusion (APSF or PSF) at one center between 1987 and 2001 were included for analysis. The minimum follow-up was 2 years after surgery (mean, 4.5 years; range, 2.0-10.2 years). The mean age of patients was 13.8 years (range, 10.7-18.2 years), with 66 females and 18 males. Multiple radiographic measures were assessed. The primary and secondary statistical analyses performed were nonparametric analyses, using the Wilcoxon-Mann-Whitney tests for the primary analysis of APSF and PSF groups. The PSF subgroup analysis was performed with the Kruskal-Wallis test. RESULTS: There were 22 patients in the APSF (open ASF in 18, and video-assisted thoracoscopy in 4) group and 62 patients in the PSF group. There were no statistically significant differences between the groups for gender, age, number of levels fused, Cobb measurement of preoperative coronal or sagittal thoracic curve magnitude, or coronal curve flexibility. The APSF group, when compared with the PSF group, had greater intraoperative correction of the coronal curve (48.3 degrees vs. 38.7 degrees, P = 0.0087) as well as final overall correction (47.2 degrees vs. 34.2 degrees, P = 0.0008). There were no significant differences seen in the sagittal alignment from T5-T12 (P = 0.3150) or the SRS outcomes data between the APSF and PSF only groups. Subanalysis of the PSF only group identified three distinct groups based on implants: hook-only constructs (n = 36), hybrid constructs of proximal hooks and distal pedicle screws (n = 15), and pedicle screw-only constructs (n = 11). Pedicle screw-only constructs corrected the coronal Cobb measurements more than the other two groups (47.5 degrees vs. hooks 37.7 degrees vs. hybrid 34.4 degrees , P = 0.0110), and to a similar extent as to the APSF group with no statistically significant difference in coronal correction (PSF, 47.5 degrees; APSF 48.3 degrees; P = 0.9014), nor any other parameter except for sagittal T5-T12 changes. There were no reoperations for implant failure/pseudarthroses in any of the patients. CONCLUSION: APSF of large thoracic curves allows greater coronal correction of thoracic curves between 70 degrees and 100 degrees, when compared with PSF alone using thoracic hook constructs, but not with the use of thoracic pedicle screw constructs. Scoliosis surgeons not using pedicle screw constructs need to decide if the modest improvement in coronal correction with a combined approach justifies its routine use in this patient population.

Adolescent↗
PubMed2006

Benefits of early aggressive management of empyema thoracis.

BACKGROUND: The end-target of the management of thoracic empyema is to obtain early rehabilitation by re-expansion of the trapped lung resulting from intrapleural infected material. Our aim was to shorten the hospitalization time and to prevent a possible thoracotomy by using video-assisted thoracoscopy initially. METHODS: Seventy patients with parapneumonic empyema were prospectively studied between January 1997 and June 2004. The patients were randomly divided into two groups. In group I (n = 35 patients), a chest tube was inserted into the patients after pleural content was evacuated and fibrins were debrided using video-assisted thoracoscopy. In group II (n = 35 patients), tube thoracostomy was carried out without using a video-assisted thoracoscope. Both groups were compared in terms of hospitalization time, open surgery for decortication and complications. RESULTS: There was no statistically significant difference between the groups from the point of view of age and sex (P > 0.05). In group I, 17.1% of the patients underwent open decortication, whereas in group II, 37.1% of the patients underwent the same procedure (P < 0.05). Whereas average hospital stay in group I was 8.3 days (range, 7-11 days), it was 12.8 days in group II (range, 10-18 days; P < 0.05). There was one bronchopleural fistula in group I, and there was one bronchopleural fistula and one death in group II. CONCLUSION: Video-assisted thoracoscopic evacuation and chest tube insertion in situ is a new therapeutic approach for pleural empyema that shortens hospital stay and reduces the necessity of open decortication.

Adult↗
PubMedDate not supplied

Chronic traumatic and congenital diaphragmatic hernias: presentation and surgical management.

BACKGROUND: The diagnosis of chronic diaphragmatic hernias, whether due to congenital defects or trauma, may be difficult to make and may rely on clinical suspicion in the setting of persistent nondiagnostic radiographic findings. Repair is indicated to avoid catastrophic cardiopulmonary compromise and/or incarceration of abdominal organs. STUDY OBJECTIVES: To review the varied presentations and treatment of chronic diaphragmatic hernia. DESIGN: Retrospective review. SETTING: University of Washington and Harborview Medical Center, Seattle, Washington. PATIENTS: Between 1997 and 2001, nine patients presented with chronic diaphragmatic hernia (two congenital cases, seven post-traumatic cases). Four cases involved the right diaphragm. The following clinical features were noted: asymptomatic, chest radiograph showing bowel herniation (n=1); chest wall mass (n=1); asymptomatic with the chest radiograph showing marked elevation of hemidiaphragm (n=1); dyspnea with the chest radiograph showing marked elevation of hemidiaphragm (n=1); diarrhea and heartburn (n=1); generalized gastrointestinal upset (n=1); recurrent pneumonia (n=2); recurring effusions (n=4); and dyspnea on exertion (n=5). INTERVENTIONS: Diagnosis was confirmed by chest radiograph in two patients, chest computed tomography scan in one patient, barium studies in three patients and thoracoscopy in three patients. All hernias were repaired via thoracotomy, and two hernias were repaired with artificial patch. CONCLUSIONS: Patients with chronic diaphragmatic hernias present with a variety of symptoms and radiographic findings. When radiology or symptoms suggest bowel involvement, barium studies are appropriate. In other cases, chest computed tomography scans and/or thoracoscopy are useful. Repair is accomplished through the ipsilateral chest, with primary repair of the diaphragm preferred over patch repair.

Adolescent↗
PubMedDate not supplied

Diagnostic yield of mediastinal exploration.

OBJECTIVE: To report our experiences of surgical diagnostic procedures in patients with unidentified mediastinal pathology. METHODS: From July 1995 to July 1999, 72 patients with mediastinal pathology had 73 surgical procedures for the purpose of tissue diagnosis. Of the 72 patients, 39 were female and 33 male, with an average age of 54 years. Mediastinoscopy and anterior mediastinotomy were performed in 54 and 15 patients, respectively (13 left and 2 right). Thoracoscopy was used in 3 cases, and 2 patients were diagnosed via cervical incision. Superior vena cava (SVC) obstruction was noted in 4 patients and four procedures were repeat procedures. Frozen section analysis was performed in 52 cases. RESULTS: Tissue diagnosis was achieved in all cases, enabling a specific diagnosis in 70 cases (97%). In 2 patients, the final diagnosis was non-specific and in 1 patient repeat biopsy was needed. The diagnoses were lymphoma (n = 32), tuberculosis (n = 20), metastatic disease (n = 11) and other pathology (n = 9). There was no operation-related mortality although 1 patient developed mediastinal haematoma, which was treated conservatively. The 2 in-hospital deaths resulted from causes secondary to the primary disease (invasive aspergilloma or Hodgkin's lymphoma). CONCLUSION: Mediastinoscopy is a safe surgical procedure with high diagnostic yield. Its routine use with mediastinotomy and thoracoscopy ensures accurate diagnosis. Careful surgical technique is mandatory in repeat procedures and SVC obstruction cases.

Adolescent↗
PubMed1999

Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study.

Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect.

Adult↗
PubMed2002

Video-assisted thoracoscopic surgery for congenital heart disease.

We report our experience with video-assisted thoracoscopy in the surgical closure of heart septal defects. Nine patients, aged 10 to 26 years, underwent operation for closure of an atrial septal defect; and 3, aged 10 to 22 years, for closure of a ventricular septal defect. Three minithoracotomies with a diameter of 2 to 3 cm were made in the fourth intercostal space of the right parasternum and the fourth and seventh intercostal spaces of the right middle axillary line, respectively. Through the openings and guided by a thoracoscope, a catheter was inserted into the superior vena cava, femorofemoral extracorporeal circulation was built, the aorta was crossclamped, and the myocardium was protected by cold cardioplegia. The right atrium was opened, and the defect was exposed with a traction suture. Primary closure of defects was performed successfully in all patients. The duration of aortic crossclamping and extracorporeal circulation ranged from 11 to 56 minutes and from 50 to 168 minutes, respectively. Postoperatively, cardiac murmur disappeared and echocardiograms showed no residual shunt. Repair of heart septal defects can be completely done with the assistance of video-assisted thoracoscopy, offering a new option with minimal incision.

Adolescent↗