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The recent explosion of interest in surgical endoscopic techniques has revived the application of an old thoracic surgical procedure--thoracoscopy. We report a case of a transthoracoscopic neodymium: yttrium-aluminum garnet laser resection of a limited-stage peripheral adenocarcinoma of the lung accomplished in an elderly man with serious chronic obstructive pulmonary disease.
Chylothorax after pneumonectomy was treated successfully by selective application of fibrin glue through a thoracoscope. Conservative therapy for 18 days failed to close the fistula. The site of leakage was identified during thoracoscopy, and fibrin glue was applied under direct vision. Leakage decreased immediately and eventually stopped completely. This technique is less invasive than standard surgical treatment and should be considered in all patients with postoperative chylothorax.
Recent advances in video technology and endoscopic instrumentation have expanded the use of thoracoscopy from diagnosis to treatment of pulmonary parenchymal disease. We recently performed 14 pulmonary wedge excisions using videothoracoscopic techniques in 10 patients (7 women and 3 men). Median age was 60 years (range, 21 to 82 years). Indications were small peripheral solitary pulmonary nodules in 4 patients, diffuse pulmonary infiltrates in 4, and recurrent pneumothoraces in 2. Thoracoscopic wedge excisions were accomplished using double-lumen endotracheal anesthesia and a percutaneous stapling device. Tissue diagnosis was obtained in all patients; 6 had benign disease, 3 had metastatic cancer, and 1 had diffuse bronchoalveolar cell carcinoma. Median operating time was 90 minutes (range, 40 to 140 minutes). There were no operative deaths. The single complication was a prolonged air leak. Median hospitalization was 5 days (range, 3 to 16 days). All patients returned to full activity within 10 days of discharge. Median follow-up was 6 months (range, 5 to 8 months). We conclude that videothoracoscopic wedge excision is a safe and effective procedure for selected small peripheral indeterminate pulmonary nodules, diffuse interstitial lung diseases, and recurrent spontaneous pneumothoraces. Further evaluation and prospective studies are indicated.
Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (less than 3 cm) in the outer third of the lung. Patients with preoperative histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttrium-aluminum garnet laser (31), endoscopic stapler (29), or both (25). The mean diameter of the lesions was 1.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2), bleeding requiring transfusion (1), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drainage was 3.3 +/- 3.0 days. Mean postoperative stay was 5.7 +/- 4.9 days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 15; radiation fibrosis, 1; sclerosing hemangioma, 1; rheumatoid nodules, 1; granuloma, 2; nocardia, 1; infarct, 1; hamartoma, 4; scar, 1; cytomegalovirus pneumonia, 1), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 13 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
The therapeutic role of thoracoscopy has expanded with advances in endoscopic surgical instrumentation and laser technology. We report a complete thoracoscopic resection of an encapsulated (stage I) thymoma with lymphocytic predominance in an elderly woman without myasthenia gravis. The patient had an uncomplicated postoperative course and was discharged on the third postoperative day. Median sternotomy with its attendant morbidity was avoided. Thoracoscopic resection of thymic neoplasms may be a useful approach in carefully selected patients.
Previously, intrathoracic organs have been approached by either thoracotomy or thoracoscopy. A technique, imaged thoracoscopic surgery, using video optics and projection of images on a screen provides another option for the thoracic surgeon. Two patients with mediastinal cysts, one bronchogenic and one esophageal, underwent surgical removal using imaged thoracoscopic surgery. Postoperative pain was markedly reduced, hospitalization shortened, and recovery accelerated. Numerous complex surgical procedures can be performed using imaged thoracoscopic surgery.
The diagnosis and management of pleural effusions have been well recognized over the years as indications for thoracoscopy. New technology has enhanced its appeal. Video-assisted thoracic surgery is a well-tolerated procedure that affords excellent visualization of the entire pleural surface. Directed biopsies of suspicious areas lead to a high diagnostic yield, particularly when compared with percutaneous biopsies. New algorithms reflect this fact. Video-assisted thoracic surgery now follows diagnostic thoracentesis as the next step in the evaluation of effusion suspicious for malignancy. Video-assisted thoracic surgery can also aid the lysis of adhesions, which might limit the effectiveness of surgical procedures to produce pleurodesis, and is an ideal tool for therapeutic management. It may be performed with general anesthesia or local anesthesia and sedation. All of the pleural fluid can be removed and this facilitates the procedure. With minimal instrumentation, pleurodesis may be performed by pleurectomy, mechanical abrasion, or talc sclerosis. Visually directed placement of chest tubes ensures adequate reexpansion of the lung.
Giant bullae of the lungs are readily recognizable on plain chest x-ray films and are rare. Only 17 of more than 500 cases of thoracoscopic treatment of bullous lung disease over the past 3 years involved giant bullae, which included both types 1 and 4. Type 1 bullae have smooth internal lining without trabeculae and type 4 have trabeculae. The indications were dyspnea in 10 cases, spontaneous pneumothorax in 6, and infection in 1. The mean age of the patients was 55 years. Five patients were oxygen dependent, 1 was wheelchair-bound, and 3 were steroid dependent. Preoperative spirometry was available in 1 patient with type 1 bullae (forced vital capacity = 95% and forced expiratory volume in 1 second = 55% of the predicted values) and in 10 patients with type 4 bullae (forced vital capacity = 46.90% +/- 15.29% and forced expiratory volume in 1 second = 23.50% +/- 7.46% of the predicted values). Under general anesthesia with one-lung ventilation, the giant bullae were excised, plicated, or contracted by the laser, depending on the type, by means of thoracoscopy. Thoracoscopic surgery was successful in all patients, and no procedure was converted to thoracotomy. The duration of anesthesia was 4.44 +/- 1.49 hours, postoperative ventilatory support 42.24 +/- 64.22 hours, and postoperative air leaks 14.59 +/- 14.11 days. All patients did very well and pain was minimal. There was no recurrence for up to 3 years of follow-up. In conclusion, thoracoscopic treatment of giant bullae of the lungs is an effective alternative to conventional thoracotomy with minimal morbidity.
Both patients and the medical profession are quick to embrace new technology, particularly when it may replace an existing surgical procedure. Unfortunately, the rapidity of acceptance is rarely associated with careful evaluation. Laparoscopy is a recent example of such widely embraced technology. Studies of laparoscopy that yielded good comparative data to more traditional methods were slow to accrue. This led to the exposure of its shortcomings through governmental reports and the lay press. To prevent this from happening in thoracoscopy, two types of studies are required so that valid conclusions about the new technology can be drawn. The first is an accounting of the new technology as procedures evolve around it. The data collected in such a study should contain basic information, including the indications for the procedure, how it was performed, procedure length, associated complications, and patient outcome. Such information provides a broad profile of the technology, emphasizing from the outset its potential strengths and weaknesses. The second type of study involves a more detailed concurrent comparison of the specific procedures utilizing this technology to the established traditional methods. Such randomized studies help to firmly establish through scientific process the place of the new technology. The Video-Assisted Thoracic Surgery Study Group was organized in early 1992 to address these concerns. From an initial four surgeons the group has grown to include more than 41 institutions. Currently the group is collecting data in a registry and has established three clinical trials to evaluate video-assisted thoracic surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Management of indeterminate solitary pulmonary nodules includes clinical assessment, radiographic examination, and bronchoscopic or transthoracic biopsy. Despite these management techniques, definitive diagnosis often remains elusive. Thoracoscopy offers another diagnostic modality to the algorithm for management of indeterminate nodules.
Surgical resection is the treatment of choice for non-small cell carcinoma of the lung. In some patients with marked impairment of pulmonary function, cardiac disease, or other medical conditions, the surgeon is faced with performing either a limited resection or carrying out nonoperative therapy. Impaired pulmonary functions are defined as a maximum breathing capacity (MBC) of 35% to 40% of predicted; forced expiratory volume in 1 second (FEV1) of less than 1 L; and a forced expiratory volume 25%-75% (FEV25-75) of less than 0.6 L. When MBC values are less than 35% of predicted; the FEV1 is less than 0.6 L; and the FEV25-75 is less than 0.6 L, elective resection is contraindicated. Useful criteria for indicating an elective limited resection include the following: (1) T1 lesion, (2) peripheral location, (3) margins easily encompassed by resection, and (4) no gross lymph node involvement. In a study of 67 patients, there was 1 postoperative death, with less than an 80% 2-year survival and a 31% 5-year survival. The role of video-assisted thoracoscopy in the management of primary lung cancer remains to be defined. When the high-risk patient can be operated on with attendant low morbidity and mortality, I believe, at the current time, a video-assisted thoracic resection for primary lung cancer is not the best option, as the patient will be offered a compromised operation, and I suspect follow-up studies will prove this correct.
Mediastinal parathyroid tissue hyperfunctions in as much as 25% of the patients with primary hyperparathyroidism, and this may be responsible for causing conventional operative procedures to fail in as much as one-third of the cases. When lesions prove to not be accessible through a cervical incision, or when a mediastinal adenoma is diagnosed before cervical procedures, median sternotomy and angiographic ablation have been considered the only options for removal. However, thoracoscopy has theoretic advantages over both. Two patients underwent successful thoracoscopic removal of a hyperfunctioning ectopic mediastinal parathyroid adenoma and their cases are presented here.
A case is presented in which an indeterminate lung lesion was extracted through an accessory incision during a video-assisted thoracic surgical lung biopsy. The lesion was malignant, and a completion lobectomy was performed. An incisional recurrence developed 5 months later, and this was treated with a wide chest wall resection and reconstruction. However, there was a second massive chest wall recurrence that proved fatal. We believe that tumor seeding to the chest wall occurred at thoracoscopy. To prevent such tumor seeding, thoracoscopic biopsy specimens should be removed in some sort of receptacle when cancer is suspected.
The resection of posterior mediastinal dumbbell tumors has until now required laminectomy and some form of open access to the thoracic cavity. Over a 1-year period, a novel surgical approach combining posterior microneurosurgical and anterior video-assisted thoracoscopy techniques was used in 4 patients. In 3 patients, the tumor was removed successfully with minimal postoperative discomfort and rapid recovery. In the fourth patient, limited thoracotomy became necessary to control bleeding. This new approach, which combines modern-day neurosurgical and general thoracic surgical techniques, appears safe and could become the preferred method for removing most benign posterior mediastinal dumbbell tumors.
Malignant schwannomas of the intrathoracic vagus nerve are rare tumors. A patient underwent resection of a mediastinal malignant schwannoma of the vagus nerve using video-assisted thoracoscopy, with no recurrence at 18 months.
Mediastinal masses are generally excised through wide thoracotomies or median sternotomies. These lesions are often benign, usually asymptomatic, discovered incidentally, and relatively easy to resect. For these reasons, a minimally invasive approach is appropriate. Videothoracoscopy allows an optimal exploration of the pleural cavity and a panoramic view of the mass. Dissection is usually easy to perform, and the mass can be extracted from the thorax through a trocar incision or through a limited "utility thoracotomy." To avoid possible tumor seeding, the mass is inserted in a plastic bag before extraction. From September 1991 to January 30, 1994, 20 mediastinal masses (6 thymomas, 2 thymic cysts, 1 hyperplastic thymus, 1 fibrous tumor of the mediastinum, 2 pleuropericardial cysts, 2 thoracic teratomas, 2 large thoracic lipomas, 3 neurogenic tumors, and 1 bronchogenic cyst) were removed through such a minimally invasive approach. Eighteen patients had an uneventful postoperative course. Two patients hemorrhaged in the immediate postoperative period, and repeat thoracoscopy was done. In 1 patient, electrocoagulation of a bleeding intercostal artery controlled the hemorrhage. In the other, the source of bleeding could not be found, and removal of the clots and irrigation of the cavity stopped the hemorrhage. Further data and long-term follow-up are necessary, but videothoracoscopy offers a new, less invasive approach for the management of noninvasive mediastinal masses.
Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate.(ABSTRACT TRUNCATED AT 250 WORDS)
Legionella pericarditis is a rare and serious manifestation of Legionnaire's disease. A case is presented in which the diagnosis was established by direct fluorescent antibody staining on a pericardial tissue specimen. Video-assisted thoracoscopy was used safely and effectively in diagnosis and management in this case.