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PubMed2001

Fluoroscopy-assisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking.

BACKGROUND: Small lesions of the peripheral lung have been detected more frequently with the recent prevalence of computed tomography (CT). Identification of these lesions is indispensable for wedge resection performed by video-assisted thoracic surgery. Previous reports of marking techniques showed some failure and complications. We have developed a new marking technique and herein describe the efficacy of this technique: fluoroscopy-assisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking. METHODS: Twenty patients underwent this procedure for 21 small peripheral pulmonary lesions approximately 10 mm in size. RESULTS: All the lesions were successfully marked and identified during fluoroscopy-assisted thoracoscopy. They were resected with sufficient margins. There were no complications related to this procedure. The pathologic examination of these 21 lesions revealed primary lung cancer in 14, atypical adenomatous hyperplasia in four, a metastatic tumor in one, and a benign tumor in two. CONCLUSIONS: This procedure is both a reliable and minimally invasive technique in thoracoscopic wedge resection for small peripheral pulmonary lesions.

Adult↗
PubMed2001

Substernal thoracoscopic guidance during sternal reentry.

Reentry sternotomy is commonplace, as more patients are returning for second, third, or more repeat cardiac procedures. Catastrophic hemorrhage remains the most dreaded complication during reentry and carries a significant morbidity and mortality. Although various methods are used to reduce the risk of hemorrhage, we have found that substernal thoracoscopy is preferable. Our experience with this technique in both adults and children is presented.

Adult↗
PubMed2002

Catamenial pneumothorax: chest X-ray sign and thoracoscopic treatment.

We report the case of a 25-year-old woman with recurrent right-sided catamenial pneumothorax. At thoracoscopy, the diaphragm presented several violet implants with holes. The presence of diaphragmatic endometrial implants was confirmed at pathologic examination. Re-review of the preoperative chest x-ray film showed 8 x 5 and 1 x 1 mm bubbles at the level of the right diaphragm associated with the homolateral pneumothorax, thus suggesting that passage of air from the genital tract through the diaphragm was responsible for the pneumothorax. This may further clarify the pathogenesis of catamenial pneumothorax which remains controversial in the literature.

Adult↗
PubMed2002

Less-invasive thoracic aortic aneurysm repair.

To minimize surgical trauma, we performed graft replacement of a descending aortic aneurysm through a minithoracotomy (12 cm) with the use of thoracoscopy and special vascular clamps. Contrast magnetic resonance angiography can be useful for preventing postoperative paraplegia by revealing the Adamkiewicz artery. The patient was satisfied with the postoperative comfort and good cosmetic result. Further refinement of the technique and instrumentation would make this technique a valuable adjunct to conventional thoracic aortic surgery.

Aged↗
PubMed2003

Robotic-enhanced biventricular resynchronization: an alternative to endovenous cardiac resynchronization therapy in chronic heart failure.

BACKGROUND: Cardiac resynchronization therapy (CRT) by pacing the left and right ventricles is an emerging option for treatment of severe heart failure with ventricular conduction disturbances. Stimulation through a coronary vein is currently the technique of choice to achieve left ventricular (LV) pacing. Unfortunately, this approach carries significant limitations and drawbacks. Therefore we explored robotic-enhanced thoracoscopic implantation of an epicardial lead as an alternative technique to stimulate the LV in cardiac resynchronization therapy. METHODS: A total of 15 patients were included in this study. Right (atrial and ventricular) leads were implanted classically through the left subclavian vein. Robotic-enhanced thoracoscopy was then performed to implant the LV epicardial lead. RESULTS: Of the 15 patients, 13 underwent successful endoscopic robotic cardiac resynchronization therapy. Two patients underwent conversion to a small thoracotomy. No perioperative complication occurred in the patients who did not undergo conversion. Acute and chronic LV lead thresholds were satisfactory in all patients, improving over time. All were subjectively and objectively improved at 4 months. As compared with conventional methods, the procedural cost was not significantly affected. CONCLUSIONS: Based on this feasibility study, we believe that robotic LV epicardial lead implantation is a valuable option to achieve biventricular resynchronization therapy. It allows for more reproducible acute thresholds for LV pacing and sensing than does the percutaneous approach; enables fine tuning of the LV lead position, thus potentially providing optimal hemodynamic benefit; and avoids the pitfalls and limitations of the endovenous approach. Therefore it deserves further prospective studies to assess its place in the therapeutic armamentarium against heart failure.

Aged↗
PubMed2003

Severe hyperhidrosis: clinical features and current thoracoscopic surgical management.

BACKGROUND: Severe hyperhidrosis is a debilitating disorder primarily affecting the palmar, plantar, and axillary regions. The purpose of our study was to review patient characteristics, surgical technique, and outcome of patients undergoing outpatient thoracoscopic sympathectomy for severe hyperhidrosis. METHODS: A series of 309 hyperhidrosis patients underwent thoracoscopy for T2-T3 sympathectomy. Of these, 180 underwent prospective evaluation to more precisely identify pre- and postoperative features. RESULTS: The primary indication for surgery was palmar hyperhidrosis (PH) in 302 of 309 patients (97.7%), although in 7 patients (2.3%) axillary hyperhidrosis (AH) was the primary indication. A family history was elicited in 74 of 132 (56.1%) and a provocative response to hand lotion was present in 101 of 132 (76.5%). Thoracoscopic sympathectomy afforded almost instantaneous cures for PH, with marked improvement in 100% for whom the sympathectomy was done. Of 180 patients prospectively questioned in detail, 173 (96.1%) had some degree of plantar hyperhidrosis. Of these, 148 (84.4%) had some improvement, with 70 (40.5%) achieving complete relief of the plantar hyperhidrosis. In 98 patients who had some complaints of AH, 68 (69.4%) were completely relieved of the AH, while 25 (25.5%) were relieved but not completely cured. In 7 patients, the primary indication for sympathectomy was AH and of these, 3 (42.9%) had complete relief, 2 (28.6%) had partial relief, and 2 (28.6%) had no relief. Of the entire series of 309 patients, 4 (1.3%) developed severe compensatory hyperhidrosis (CH). In 180 prospectively questioned patients, CH was present in 81 (45%). CONCLUSIONS: The most frequent presentation of hyperhidrosis involves the hands and feet. A family history of the disorder is common, and there is usually a provocative effect with hand lotion. Sympathectomy at the level of the T2-T3 ganglia is curative for PH, and in 80% of instances will improve plantar hyperhidrosis when in combination with PH. Sympathectomy for AH is not as effective as for PH. CH is common, occurring in nearly half, but only rarely is extreme and problematic. Bilateral thoracoscopic sympathectomy may be safely done as an outpatient procedure for most patients.

Adolescent↗
PubMed1981

Diffuse, mixed malignant pleural mesothelioma.

Forty-six patients with diffuse, mixed malignant pleural mesothelioma were treated between January, 1970, and May, 1979. All had a history of exposure to asbestos. The diagnosis was established by thoracentesis in 3 patients, thoracoscopy in 28, thoracotomy in 5, and minithoracotomy in 9. Mediastinoscopy was performed in 31 patients and bronchoscopy in 32. Mediastinoscopy was positive in only 1 patient, and in no patient was bronchoscopy positive. Ten patients received no definitive therapy and survived an average of 9.1 months (1 lived for 16 months). Thirty-one patients received chemotherapy and survived an average of 9.6 months, the 2 longest survivors each lived for 24 months. Five patients appeared to have early disease and therefore underwent thoracotomy. In only 2 of these patients did resection of all gross disease appear possible. One patient with incomplete removal is still alive after 9 months. The other 4 are all dead, having survived an average of only 6.75 months. We believe that pleural mesothelioma should be considered an unresectable neoplasm because of its multicentric origin and its diffusely invasive nature, and that attempts at partial or complete resection are not indicated. Until prospective, controlled studies demonstrate otherwise, patients with diffuse, mixed malignant mesothelioma should have the most benign surgical procedure necessary to establish a diagnosis.

Adult↗
PubMed1997

Visualization of ventricular fibroelastoma with a video-assisted thoracoscope.

Left ventricular papillary fibroelastomas are associated with a high risk of cerebral embolization. Two-dimensional echocardiography and intraoperative transesophageal echocardiography are helpful in diagnosing tumors, planning a surgical approach, and achieving adequate excision. A video-assisted thoracoscope via the left atrium was used to visualize a left ventricular papillary fibroelastoma. Thoracoscopic visualization facilitated excision of a mass within the chordae tendineae between the anterolateral papillary muscle and the left ventricular wall. Video-assisted thoracoscopy greatly facilitates exposure/excision of deeper intracavitary left ventricular masses.

Endoscopy↗
PubMed1997

Single-stage bilateral, video-assisted thoracoscopic lung volume reduction operation.

Lung volume reduction (LVR) produces significant clinical and objective improvement in selected patients with diffuse emphysema. Unilateral and bilateral approaches have been successfully employed. A median sternotomy approach is the standard for bilateral LVR, whereas video-assisted thoracoscopy has been used to perform unilateral LVR. Encouraging video-assisted thoracoscopic results with sequential, staged, bilateral LVR have been shown. This report describes an alternate technique of single-stage, bilateral LVR for end-stage emphysema.

Emphysema↗
PubMed1997

Thoracoscopic transmyocardial laser revascularization.

BACKGROUND: Transmyocardial laser revascularization is a promising surgical technique used to treat nonreconstructable ischemic heart disease. Recent clinical data show that this technique improves the regional perfusion of ischemic myocardium and reduces angina. Presently, transmyocardial laser revascularization requires an open, lateral thoracotomy. We report here the use of thoracoscopic techniques to perform transmyocardial laser revascularization in a closed chest fashion. METHODS: Five Yorkshire farm pigs underwent left chest thoracoscopic exploration and pericardiotomy. A specialized laser handpiece then was introduced into the chest and thoracoscopic transmyocardial laser revascularization was performed (one channel per square centimeter) using an 800-W CO2 laser. RESULTS: Video analysis and gross pathology revealed that the anatomic area accessible to thoracoscopic transmyocardial laser revascularization included the entire left ventricular free wall distributions of the left anterior descending, left circumflex, and posterior descending arteries, from base to apex. Standard hematoxylin and eosin staining confirmed the creation of complete and patent 1-mm-diameter transmural channels throughout these distributions. CONCLUSION: We have shown that transmyocardial laser revascularization can be performed effectively and safely by thoracoscopy, and that this less invasive technique may reduce morbidity and provide a more cost-effective alternative therapy for nonreconstructable ischemic heart disease.

Animals↗
PubMed1998

Thoracoscopic lobectomy with endoarterial vascular control: an experimental study in swine.

BACKGROUND: Video-assisted lobectomy lacks vascular control and presents the potential for serious hemorrhage in a closed cavity. The use of a lighted, flow-directed balloon catheter in the pulmonary artery as an endovascular control device was evaluated. METHODS: A modified light-bearing Swan-Ganz catheter was placed in the left or right pulmonary artery using fluoroscopy. The lit catheter was identified easily through the arterial wall at thoracoscopy. Its inflation allowed the control of proximal blood flow as required. Fully thoracoscopic lobectomy was carried out by isolating and dividing the lobar branches of the pulmonary artery, the pulmonary vein, and the bronchus in anesthetized swine. RESULTS: Forty-two video-assisted anatomic lobectomies were completed in 30 pigs with balloon catheter control of the pulmonary artery. The balloon effectively controlled experimental hemorrhage caused by puncturing arterial branches (n = 4). It allowed the transection of unlooped lobar arteries (n = 42) and the main interlobar pulmonary artery (n = 3). Catheter displacement back to the heart occurred in 5 animals and balloon catheter technical failures occurred in 3. CONCLUSIONS: The lighted, flow-directed balloon catheter was an effective means of avoiding acute hemorrhage and achieving vascular control in a swine lobectomy model.

Animals↗
PubMed1998

Experience with the two-windows method for mediastinal lymph node dissection in lung cancer.

BACKGROUND: Continuing to refine minimally invasive thoracoscopic surgical procedures, we have established the two-windows method. METHODS: Skin incisions required by this method consist of a 2- to 3-cm skin incision posteriorly, and a 2- to 3-cm skin incision anteriorly in the fourth intercostal space, with the inferior angle of the scapula as the midpoint. We used this method to perform pulmonary lobectomies in combination with thoracoscopy and mediastinal lymph node dissection in 100 consecutive patients with lung cancer (preoperative diagnosis, stage I, T1 N0 M0). RESULTS: The mean operative time was 2 hours 46 minutes, the mean blood loss was 68.2 mL, and the mean number of mediastinal lymph nodes dissected was 24.3. In developing this minimally invasive thoracoscopic procedure, which facilitates mediastinal lymph node dissection, we realized that it is best performed through the fourth intercostal space. Because the tracheal bifurcation can be seen directly below this level, surgical manipulation in this area can be easily performed. This enables the same extent of mediastinal lymph node dissection as that performed during a standard thoracotomy. Another advantage of this method is that a standard posterolateral thoracotomy incision can be made whenever necessary by simply connecting the two incisions. CONCLUSIONS: We believe that the two-windows method is capable of serving as the standard method for the surgical treatment of stage I lung cancer.

Adult↗
PubMed1998

Thoracoscopic pleural tent.

Lung volume reduction has been performed in patients with advanced emphysema to relieve dyspnea and improve exercise tolerance. Median sternotomy and video-assisted thoracoscopy have been proposed as equally adequate approaches; however, prolonged postoperative air leakage is the most prevalent complication in all series. For this reason, on the basis of the experience achieved with the median sternotomy approach, buttressing of the suture line with different materials and techniques for space reduction have been proposed. We describe a technique to create a pleural tent after thoracoscopic volume reduction. The thoracoscopic creation of a pleural tent is feasible and results in a duration of postoperative air leaks and hospital stays similar to that achieved with stapler line buttressing.

Endoscopy↗
PubMed1999

Minimally invasive internal thoracic artery harvest: the hybrid approach.

BACKGROUND: Safe harvesting of the left internal thoracic artery is a difficult problem during minimally invasive coronary artery bypass grafting without cardiopulmonary bypass. A complete internal thoracic artery dissection through a limited approach is technically demanding and time consuming and different techniques have been proposed. METHODS AND RESULTS: Based on our experience, the different surgical approaches and technical considerations are reviewed. CONCLUSIONS: A hybrid technique using dissection under direct vision and completed by thoracoscopy is discussed and proposed as our preferred technique of internal thoracic artery harvesting.

Aged↗
PubMed1999

Transaortic video-assisted removal of a left ventricular thrombus.

A mobile and pedunculated left ventricular thrombus was developed after acute myocardial infarction in a 59-year-old man, and was successfully removed surgically through the aortic valve using a video-assisted thoracoscope. Transaortic video-assisted thoracoscopy greatly facilitated exposure of the interior of the left ventricle and preserved left ventricular function by avoiding ventriculotomy.

Endoscopy↗
PubMed1999

Visualization of diaphragmatic fenestration associated with catamenial pneumothorax.

Catamenial pneumothorax is a rare entity of unknown etiology characterized by recurrent accumulation of air in the thoracic space during or preceding menstruation. We documented the presence of a diaphragmatic fenestration during thoracoscopy, lending support for hypotheses involving diaphragmatic defects as possible avenues of air collection in the thorax.

Adult↗
PubMed2006

[Minimally invasive esophagectomy].

INTRODUCTION: Currently, the bases for the treatment of esophageal cancer are surgical resection and chemotherapy. Among the various surgical techniques used, minimally invasive esophagectomy (MIE) aims to reduce surgical aggression and cardiopulmonary complications while maintaining basic oncological principles. We present the results of our initial experience with this technique in the treatment of esophageal cancer. MATERIAL AND METHOD: Fourteen patients with a diagnosis of esophageal cancer were selected to undergo MIE in three stages: right thoracoscopy, laparoscopy, and left cervicotomy with cervical esophagogastric anastomosis. Histological diagnosis was epidermoid carcinoma (n = 11) and high grade dysplasia (n = 3), one of which was highly suspicious of malignant transformation. After extension studies, preoperative clinical stages were as follows: stage 0 (n = 3), stage IIA (n = 10), and stage III (n = 1). Seven patients were treated with chemotherapy and neoadjuvant radiotherapy and the remainder underwent surgery without prior treatment. RESULTS: The mean operating time was 299 minutes (range: 195-425). The conversion rate was 14% (n = 2). Mortality was 0% and morbidity was 50%, consisting of three major complications and four minor complications. No anastomotic dehiscence or wound infections were observed. Complete (R0) resections were achieved in 92.8% (n = 13). Transfusion needs were 1.1 U/patient. The mean number of nodes removed was 10.2/patient (range: 5-17). The mean length of hospital stay was 21 days (range: 9-64). Postoperative follow-up ranged from 1 to 17 months. All patients were alive and disease-free except for one patient with liver metastases. CONCLUSIONS: Although MIE is a demanding technique, we believe that it is technically feasible in the treatment of esophageal cancer with acceptable postoperative morbidity and mortality. Consequently, it should be considered as an alternative to open surgery in selected patients.

Aged↗
PubMed2004

Accuracy of EUS in staging of T4 lung cancer.

BACKGROUND: Increasingly, EUS is being used to stage lung cancer. Direct mediastinal invasion (T4) by lung cancer is stage IIIb disease. Patients in this stage have a 5-year survival of less than 5% and generally are offered chemotherapy without surgery. This study evaluated the accuracy of EUS in detecting T4 lung cancer. METHODS: The study included all patients with lung cancer who had EUS staging and subsequent staging at surgery, or for whom there was unequivocal confirmation of unresectability (T4) by thoracoscopy, thoracotomy or presence of malignant pleural effusion, or definite invasion of great vessels/adjacent organs on CT. RESULTS: A total of 175 of 308 patients with lung cancer who underwent EUS over a 5-year period (1997-2002) had subsequent confirmatory tumor staging. Ten patients were found by EUS to have stage T4 tumors; 7 were confirmed to be T4 by either surgical exploration (2), CT demonstration of aortic invasion (3), or documentation of malignant pleural effusion (2). Three of the 10 (30%) patients found to have stage T4 tumors by EUS had T2 disease at surgery and underwent curative resection. Of the remaining 165 patients without evidence of T4 disease at EUS, only one was found to have aortic invasion (T4) at surgery. EUS had a sensitivity of 87.5%, specificity of 98%, positive predictive value of 70%, and a negative predictive value of 99% for detecting T4 disease. CONCLUSIONS: Caution is warranted when unresectability of lung cancer is based solely on tumor invasion into mediastinal soft tissue at EUS. Overstaging occurs when a tumor appears to invade the pleural layer without mediastinal organ invasion. Confirmation of unresectability by other diagnostic modalities is warranted in such instances.

Adult↗