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PubMed1995

Thoracoscopic debridement of loculated empyema thoracis in children.

The appropriate management of multiloculated empyema thoracis remains controversial. During a 7-month period, we have managed multiloculated empyema with early thoracoscopic debridement in three consecutive pediatric patients. Chest tubes were removed 7 +/- 1 (mean +/- standard deviation) days after thoracoscopy and discharge from hospital was on postoperative day 8 +/- 1. We suggest that early thoracoscopic debridement of multiloculated empyema thoracis in children is safe and efficacious.

Adolescent↗
PubMed1996

Giant pericardial cysts.

Pericardial cysts are most commonly incidental radiologic findings of little clinical consequence. We present the unusual history of 2 patients in whom pericardial cysts were of massive sizes and caused significant symptoms; in 1, progression of the cyst size had been documented over 25 years. Diagnostic difficulties encountered and the utility of video-assisted thoracoscopy are described.

Humans↗
PubMed1996

Minimally invasive coronary artery bypass grafting.

BACKGROUND: Standard options for the invasive management of proximal disease of the left anterior descending coronary artery include coronary artery bypass grafting with a left internal mammary artery and percutaneous transluminal coronary angioplasty. METHODS: We describe a surgical technique for bypass of the left anterior descending coronary artery with a left internal mammary artery without median sternotomy and without cardiopulmonary bypass. Thoracoscopy is used to harvest the internal mammary artery, whereas the mammary-coronary artery anastomosis is performed under direct vision through a limited anterior thoracotomy. RESULTS: We have performed this procedure successfully in 3 patients with minimal morbidity and shortened hospital stay. Average operative time was 3 hours and postoperative hospital stay averaged less than 48 hours. CONCLUSION: Although experience is limited and follow-up is very short, with further experience, this less invasive surgical technique may become a viable option for the management of proximal left anterior descending disease.

Adult↗
PubMed1996

Complications of video-assisted thoracic surgery: a five-year experience.

BACKGROUND: Although thoracoscopy was originally described in 1910, recent developments in video-assisted surgical techniques and endoscopic equipment has expanded the application of video-assisted surgical procedures in the field of thoracic surgery. METHODS: In an effort to define both high-risk patients for video-assisted thoracic procedures and high-risk video-assisted thoracic surgical procedures, we reviewed the experience of four surgical institutions from June 1991 through May 1995. We looked specifically at complications resulting from the 937 video-assisted thoracic procedures performed during this period. RESULTS: Perioperative incidents or complications occurred in 35 patients (3.7%), and 116 procedures (12.4%) were converted to a thoracotomy. The in-hospital mortality rate was 0.5%, and death occurred principally in patients operated on for malignant pleural effusion. The overall incidence of postoperative complications was 10.9%, and the most prevalent complications were prolonged air leak (6.7%) and pleural effusion (0.7%). CONCLUSIONS: The incidence of complications was acceptable and, except for that of prolonged air leak, did not differ significantly from that resulting from analogous open procedures. Video-assisted thoracic surgery appears safe and particularly useful for some indications. However, the possibility of dramatic life-threatening perioperative complications requiring emergency conversion to thoracotomy justifies the fact that only trained thoracic surgeons should perform video-assisted thoracic surgical procedures.

Adolescent↗
PubMed1996

VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema.

BACKGROUND: There are approximately 60,000 new cases of postpneumonic empyema every day in the United States. Usually the fibrinopurulent stage of this complication has been treated by either tube thoracostomy or thoracotomy and debridement. According to the literature, thoracoscopic treatment has not been used often for this disease. METHODS: Sixty-four cases of postpneumonic fibrinopurulent empyema were operated on at our institution: 33 cases (group I) by means of a formal thoracotomy and 31 cases (group II) by thoracoscopy. In the thoracoscopic subset the data were collected prospectively since 1992. These results were compared with those of a historical series treated by thoracotomy between 1985 and 1991. Both populations were similar in terms of age (mean, 49 years), number of cases (33/31), sex (2.1 male/female), and comorbid status. RESULTS: Mean preoperative length of the medical management (11.5 versus 17 days) (p = 0.03) and chest tube removal (4.3 versus 6.1 days) were shorter in group II than in group I (p = 0.02). Morbidity and mortality were identical: one death and five complications in each group. Mean operative time was similar in both groups, and hospital stay was shorter in the video-assisted thoracic surgery group (6.8 versus 11.2 days) (p = not significant). Three patients from group II needed utilitary thoracotomies for debridement completeness (10% conversion rate). CONCLUSIONS: We conclude that video-assisted thoracic surgical treatment has the same rate of success as open thoracotomy but offers substantial advantages over thoracotomy in terms of resolution of the disease, hospital stay, and cosmesis. A prospective and randomized study is needed to confirm the findings of this nonrandomized initial experience.

Adolescent↗
PubMed1996

[Value of video-assisted thoracic surgery in internal medicine. Apropos of 7 cases].

Since a few years, the medical thoracoscopy has already been used specially for the diagnostic and therapeutic taking up of the pleural pathology. Behind it, the video-assisted thoracic surgery has been improved since 1990. As a surgical technology, it proved its interest refering to the classical thoracotomy by lessening operative morbidity and mortality. The authors discuss its main indications about seven cases, recruted in the internal medicine service and operated in the thoracic surgery service of the Val-de-Grâce hospital. Some of these indications are now admited by most of the authors: 1) diagnostic aims: pulmonary biopsy in case of interstitial pathology, of pulmonary peripheral under-pleural nodule and sometimes of solid tumors of the mediastinum, specially of some lymph-nodes. 2) Therapeutic aims: the spontaneous pneumothorax treatment of the adult remains the most classical indication; the thoracic sympathectomy, the creation of pleuropericardial windows and the resection of benign tumors of the mediastinum are now well acknowledged indications.

Humans↗
PubMed1994

Thoracoscopic cervicodorsal sympathectomy: preliminary results.

PURPOSE: The purpose of this study was to determine the feasibility, safety, and efficacy of thoracoscopic cervicodorsal sympathectomy. METHODS: From March 1990 to December 1993, we performed 21 thoracoscopic sympathectomies in 19 patients. There were 13 women and six men; age 17 to 64 years, mean 37 years. Thirteen procedures were performed on the left side and eight on the right. Indications for surgery were causalgia/reflex sympathetic dystrophy in nine patients, Raynaud's/vasculitis in six, hyperhidrosis in five, and medically refractory cardiac arrhythmia in one. RESULTS: The T1-4 sympathetic ganglia were readily identified, dissected free, and resected thoracoscopically in 19 cases, and the T3-7 ganglia were resected with thoracoscopy in one case. One case required conversion to an open thoracotomy because of dense scar from a previous first rib resection, which obscured the anatomy. Histologic confirmation of ganglia were obtained in all 21 cases. Operative duration ranged from 1.0 to 3.5 hours. Estimated blood loss was 5 to 300 cc, mean 42 cc, median 10 cc. No patient required transfusion. All 21 patients had an excellent immediate sympathectomy response. Transient Horner's syndrome developed in two patients. Postoperative residual pneumothorax (< 10%) occurred in three cases and resolved spontaneously without further treatment. In one patient pleural effusion and pneumothorax developed, which were treated with the reinsertion of the chest tube. Postoperative pain was well controlled with oral analgesics. Hospital stay was 1 to 4 days, mean 2 days, median 1 day. Follow-up at 1 to 42 months, mean 11 months, median 6 months, showed continued evidence of sympathectomy effect in all patients, except one who died of her underlying disease 1 month after operation. CONCLUSIONS: We conclude that thoracoscopic sympathectomy is feasible, safe, and effective. Further studies are indicated to confirm its long-term benefits and to determine optimal thoracoscopic techniques.

Adolescent↗
PubMed1995

Thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax.

Initial experience of thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax is reported. Thirty-three out of 49 patients admitted with spontaneous pneumothorax were suitable for treatment with this minimally invasive method. This series demonstrates that this surgical management offers early discharge and return to normal activities with excellent medium-term results, despite the three early failures. It is felt that with increased experience in thoracoscopy and improved selection of patients, thoracoscopic bullectomy and pleurodesis will become the treatment of choice for primary spontaneous pneumothorax.

Adolescent↗
PubMed1994

Thoracoscopic use of laser in intractable pneumothorax.

A neodymium:yttrium, aluminum, garnet (Nd:YAG) laser was used via the instrumentation port of a standard thoracoscope for the sealing of air leaks, ablation of bullae, transection of adhesions and partial parietal pleurectomy in 13 patients with intractable pneumothorax. The mean duration of tube thoracostomy prior to treatment was 10 days (range 4 to 21 days). All patients had intractable air leakage. Three patients had chronic lung collapse of over 50% despite adequate chest drainage. All cases were treated with thoracoscopic laser. The source of air leakage was found to be ruptured bullae in 11 cases and a lung tear in 2 cases. In five cases the bullae were multiple. In 11 cases the air leakage stopped within 24 h of treatment, with a single self-limiting episode of recurrent air leakage. In two of the cases of chronic pneumothorax the lung failed to expand because of sizable bronchopleural fistulae. They required thoracotomy stapling of bullae and limited thoracoplasty. The mean duration of tube thoracostomy after thoracoscopic laser in the 11 successfully treated patients was 2.72 days (range 1 to 5 days). We conclude laser-assisted thoracoscopy is a useful therapeutic option when treating persistent air leakage. In most cases this method prevents prolonged periods of tube thoracostomy and obviates thoracotomy. In cases of chronic collapse of the lung with bronchopleural fistulae this technique may not be successful.

Adolescent↗
PubMed2004

Imprint cytology for detecting metastasis of lung cancer in mediastinal lymph nodes.

BACKGROUND: Lymph node metastasis of lung cancer has been evaluated with histologic examination. We studied the usefulness of cytologic diagnosis for detecting metastasis of lung cancer in mediastinal nodes. METHODS: Five hundred twelve stations of mediastinal nodes in 157 patients with lung cancer were excised for staging of the disease through mediastinoscopy or thoracoscopy. Among them, 474 stations of mediastinal nodes in 151 patients were examined for metastasis both with imprint cytology and with hematoxylin-eosin histology independently. The final diagnostic decision was made by overall pathologic information, including cytology and histology. The diagnostic accuracies were compared between cytologic and histologic examinations. RESULTS: Cytologic examination identified 66 positive stations and 2 suspicious stations in 45 patients, whereas histologic examination identified 61 positive stations in 42 patients. The final pathologic diagnosis was 70 positive stations and 1 suspicious station in 45 patients. The sensitivity, accuracy, and negative predictive value of cytologic examination for node metastasis were 95.7%, 99.4%, and 99.3%, respectively, and those of histologic examination were 87.1%, 98.1%, and 97.7%, respectively. On a patient basis the sensitivity, accuracy, and negative predictive value of cytologic examination were 100%, 100%, and 100%, respectively, whereas those of histologic examination were 93.8%, 98.0%, and 97.2%, respectively. An additional 3 patients (2.0%) who had contralateral mediastinal node metastasis diagnosed only with cytology were identified with upstaged disease. CONCLUSIONS: Imprint cytology for detecting metastasis of lung cancer in mediastinal nodes has high sensitivity and accuracy and is no less useful than histologic examination.

Adult↗
PubMed2005

Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors.

BACKGROUND: Robotic surgical systems are most effective for operations in areas that are small and difficult to reach. Ideal indications for this new technology have yet to be established. The esophagus possesses attributes that are interesting for general thoracic robotic surgeons. METHODS: Robotic-assisted thoracoscopic surgery (RATS) using the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) was performed in six patients with esophageal tumors. This comprised the dissection of the intrathoracic esophagus including lymph node dissection in four patients suffering from esophageal cancer and the extirpation of a benign lesion (one leiomyoma and one foregut cyst) in the remaining two patients. RESULTS: All procedures were completed successfully with the robot. The median overall operating time was 173 (160-190) minutes in the oncologic cases and 121 minutes in the benign cases, including the robotic act of 147 (135-160) minutes and 94 minutes, respectively. There were no intraoperative complications. One patient had to undergo a redo thoracoscopy because of a persistent lymph fistula. One cancer patient died after 12 months due to tumor progression and another patient had to be stented due to local tumor recurrence 19 months postoperatively. CONCLUSIONS: This first small series of various esophageal pathologies treated by robotic-assisted thoracoscopic surgery supports the impression that the esophagus is an ideal organ for a robotic approach. The potential of the da Vinci system, especially for oncologic indications, remains to be proven in future clinical trials.

Adenocarcinoma↗
PubMed2006

Thoracoscopic repair of tracheoesophageal fistula in a septuagenarian.

We report the case of a 79-year-old female with clinical and radiographic evidence of congenital H-type tracheoesophageal fistula. Past medical history included recurrent pneumonia and episodic cough with food or fluid intake. She exhibited Ohno's sign during the dysphagia evaluation. A video swallow study demonstrated evidence of aspiration. Esophagogram and bronchoscopy identified the fistulous tract. Repair of the anomaly was performed using a minimally invasive thoracoscopic approach. In our experience, excellent visualization and magnification of the anatomic field with use of thoracoscopy allowed for relative ease of dissection and resection of the tract with minimal postoperative morbidity.

Aged↗
PubMed2006

Congenital bronchial atresia associated with spontaneous pneumothorax.

A 36-year-old woman presented with left chest pain and frequent symptoms of upper respiratory infection. Chest roentgenograms revealed a left pneumothorax and apical bulla, and hyperlucency in the left pulmonary field. She was diagnosed with congenital bronchial atresia associated with a left spontaneous pneumothorax. A thoracoscopy-assisted left superior segmentectomy was performed. There was no recurrence of the pneumothorax or symptoms of recurrent upper respiratory infection at the 1-year follow-up examination. Bulla formation was believed to have resulted from emphysematous changes in the peripheral lung due to congenital bronchial atresia. The pneumothorax may have occurred due to rupture of the bulla.

Adult↗
PubMed2006

Thoracoscopic lobectomy: a safe and effective strategy for patients receiving induction therapy for non-small cell lung cancer.

BACKGROUND: Thoracoscopic lobectomy is an accepted oncologic approach for early stage non-small cell lung cancer (NSCLC). We conducted a retrospective study of patients who underwent lobectomy after induction therapy to determine the feasibility of thoracoscopic lobectomy compared with conventional thoracotomy lobectomy. METHODS: The outcomes of 97 consecutive patients with NSCLC who received induction therapy followed by lobectomy from 1996 to 2005 were reviewed. Outcome variables analyzed included complete resection, chest tube duration, length of hospitalization, 30-day mortality, hemorrhage, pneumonia, respiratory failure, and other major complications. The Student t test and chi2 or RxC contingency tables were used to compare continuous and categoric variables, respectively. RESULTS: Lobectomy was performed by thoracotomy in 85 patients and thoracoscopically in 12 patients (1 conversion), with complete resection in all patients. All patients received induction chemotherapy, and 74 (76%) received induction radiotherapy as well: 66 of 85 (78%) in the thoracotomy group and 8 of 12 (67%) in the thoracoscopy group. The overall median survival was 2.3 years, with no difference between the groups. Patients undergoing a thoracoscopic lobectomy had a shorter median hospital stay (3.5 vs 5 days, p = 0.0024) and chest tube duration (2 vs 4 days, p < 0.001). There were no significant differences in 30-day mortality, hemorrhage, pneumonia, or respiratory failure. CONCLUSIONS: Thoracoscopic lobectomy is a feasible approach for selected patients undergoing resection after induction therapy, and is associated with shorter hospital stay and chest tube duration. Long-term follow-up of survival will determine the role of thoracoscopic lobectomy in the management of patients after induction therapy.

Adult↗
PubMed2006

[Radical surgery for mesothelioma].

Good results obtained by the team from Boston increased the interest in pleuropneumonectomy for mesothelioma. Adjuvant high-dose hemithoracic radiation after surgical resection decreased the local recurrence rate from 35 to 13%. The high rate of peritoneal (26-31%), controlateral pleural and pericardial recurrences justify the routine practice of preoperative laparoscopy and controlateral thoracoscopy and a pleuropneumonectomy without pericardotomy and diaphragmatic resection. The diaphragm is lowered to facilitate radiotherapy. Chemotherapy may be performed postoperatively.

Chemotherapy, Adjuvant↗
PubMed2006

The undiagnosed pleural effusion.

The most common causes for undiagnosed transudative effusions are congestive heart failure and hepatic hydrothorax. Pleural fluid N terminal pro-brain natriuretic peptide levels higher than 1500 pg/mL are virtually diagnostic of congestive heart failure. The most common causes for undiagnosed exudative pleural effusions are malignancy, pulmonary embolism, and tuberculosis. Clinical characteristics of patients with a malignant pleural effusion are symptoms for more than 1 month, absence of fever, blood-tinged pleural fluid, and CT findings suggestive of malignancy. Thoracoscopy is useful to establish the diagnosis of malignancy and tuberculosis.

Bronchoscopy↗
PubMed2004

Quantitation of lung sealing in the survival swine model.

PURPOSE: Small intercostal spaces and limited pleural space significantly limits the use of 12-mm stapling devices in pediatric thoracoscopic surgery. The goal of this study was to compare sealing of lung tissue by the 5-mm Ligasure (Valley Lab, Boulder, CO) device to a standard 12-mm Endo-GIA stapler (US Surgical, Norwalk, CT). METHODS: Institutional Animal Care and Use Committee (IACUC) approval was obtained (#A3-02). Sixteen 10-kg female swine were divided between 2 survival surgical groups. Lung biopsy sections of the lingula were taken by 2 methods: group A, left anterolateral thoracotomy employing a 12-mm Endo-GIA stapler and group B, left thoracoscopy employing the Ligasure 5-mm instrument. After a 7-day survival period, lung burst pressures were measured by flow-controlled insufflation into the trachea. RESULTS: Burst pressure measurement reflects the first air leak. By Student's t test analysis there were no statistically significant differences between the burst pressures, biopsy weights, or operating times. Fifty percent (4 of 8) of the animals in group A (Endo-GIA), and 50% (4 of 8) of the animals in group B (Ligasure) developed the first air leak in the nonoperative lung. Two animals, one from each group, had evidence of intrapleural infections at the time of necropsy. These were asymptomatic and did not appear to affect burst pressure measurement. CONCLUSIONS: After 7 days of healing, lung biopsy sites created with both the Ligasure and the Endo-GIA stapler have burst strengths equal to or greater than that of normal lung tissue in the swine survival model.

Animals↗