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At least 1,387 records · Page 77Linked to original sources
PubMed1996

Complications of minimal-access surgery in children.

Minimal-access surgery (MAS) is rapidly becoming the surgical approach of choice for a variety of surgical disorders in adults, but its use in children remains a relative novelty. Most pediatric surgeons continue to harbor justifiable concerns about the morbidity of this modality owing to the cumbersome nature of the instruments and the technical difficulty associated with two-dimensional views. The purpose of this study was to determine the complication rate and the lessons learned from the use of MAS in performing a variety of procedures in a large series of children. To determine complications, the authors reviewed the medical records of all children (n = 636; age range, 1 month to 19 years) who underwent laparoscopy (LAP) or thoracoscopy (THO) during a 5-year period (January 1, 1990 through December 31, 1994). The follow-up ranged from 1 week to 45 months. THO was performed in 62 children. Conversion to thoracotomy occurred in eight children (13%), because of inability to localize the lesion (3), unresectibility (2), inadequate tissue sample (1), unsafe access (1), hypoxemia (1), or inadvertent esophagotomy (1). Postoperatively, two ventilator-dependent children had tension pneumothorax after lung resection and required chest tubes. LAP was performed on 574 children, with conversion to laparotomy occurring in 15 (2.6%), because of technical reasons (10) or intraoperative complications (5). The complication rate of LAP was 2% (12 of 574). Early in the experience, intraoperative complications that led to laparotomy included hemorrhage during appendectomy (2), cholecystectomy (1), and splenectomy (1); and esophagotomy during a fundoplication (1). Other technical problems in the postoperative period were a malpositioned Nissen fundoplication and a gastric volvulus after gastrostomy and Nissen fundoplication owing to improper gastrostomy tube position. In addition, two children had a hernia at the umbilical trocar site that had been used for contralateral inguinal exploration, and cellulitis developed in three patients when a gastrostomy tube was brought out through a trocar site. Other complications not specific to MAS included pelvic abscess after appendectomy (5); small bowel obstruction after jejunostomy catheter placement (1) and combined cholecystectomy/appendectomy (1); enterocolitis (1) and severe hyponatremia (1) after pull-through for Hirschsprung's disease; and pneumonia after splenectomy (1). The overall complication rate of MAS was 4% (26 of 626), and there were no deaths. The initial use of MAS was associated with technical errors, which decreased with experience. Based on this study, the authors recommend (1) routine placement of a thoracostomy tube in children after THO if they require postoperative ventilator support; (2) using the open hernia sac to place a 70 degrees telescope for contralateral inguinal exploration; and (3) not using a trocar site for gastrostomy tube placement in immune-suppressed patients. With appropriate training and experience, MAS can be used safely in children, for a wide variety of diseases, with minimal morbidity and mortality.

Adolescent↗
PubMed1997

Diagnostic value of transbronchial, thoracoscopic, and open lung biopsy in immunocompetent children with chronic interstitial lung disease.

OBJECTIVES: To evaluate the diagnostic value of transbronchial biopsy (TBB), video-assisted thoracoscopy (VAT), and open lung biopsy (OLB) in immunocompetent children with chronic, diffuse infiltrates; to identify factors that may predict diagnosis in children requiring biopsy; to determine whether age, number of biopsies, or type of procedure are associated with diagnostic yield in children undergoing transthoracic biopsy; and to compare morbidity of VAT with that of OLB. STUDY DESIGN: As part of a prospective, descriptive study to define the clinical spectrum of pediatric interstitial lung disease, 30 immunocompetent children required TBB, VAT, and/or OLB for diagnosis of diffuse infiltrates. We reviewed and analyzed the following clinical variables: age; preoperative diagnosis; type of procedure; number of lobes undergoing biopsies; durations of surgery, chest tube insertion, and hospitalization; tissue diagnosis; and complications. RESULTS: Specific diagnoses were made in 50%, 60%, and 53% of patients undergoing TBB, VAT, and OLB, respectively. A variety of rare disorders was found, and tissue diagnosis confirmed the preoperative diagnosis in 25% of all procedures. For patients who underwent transthoracic biopsy, patient age of greater than 24 months was significantly associated with increased diagnostic yield, but the number of lobes biopsied and type of procedure were not. VAT was associated with shorter operating time, chest tube placement, and hospitalization when compared with OLB. The complications of VAT and OLB were comparable. CONCLUSION: Lung biopsy is an important tool for the diagnosis of interstitial lung disease in immunocompetent children, but the diagnosis of many children, particularly those aged 2 years or younger, remains uncertain.

Adolescent↗
PubMed1996

Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy.

OBJECTIVE: Total esophagectomy with en bloc mediastinal lymphadenectomy for cancer carries a substantial morbidity and mortality rate. To investigate the feasibility of thoracoscopic technique, we carried out an extensive laboratory study. Encouraged by our excellent results, we conducted a clinical trial. METHODS: From September 1994 to September 1995, 39 patients thoracic esophageal cancer lesions not invading surrounding organs underwent total esophagectomy with mediastinal lymphadenectomy by means of thoracoscopy. Ages ranged from 47 to 86 years. The procedures were conventional except for the thoracic portion, which was performed as a thoracoscopic procedure with six trocar holes instead of thoracotomy. All harvested lymph nodes were counted for each station. Spirometric data and plethysmographically determined vital capacity were measured before and after operation for all patients. RESULTS: All procedures were accomplished as scheduled, and none was converted to open thoracotomy. The operating time was 200 +/- 41 minutes (mean +/- standard deviation). Estimated blood loss was 270 +/- 157 ml. The harvested lymph nodes numbered 19.7 +/- 11.1 per patient. Seventeen patients (45%) had positive lymph nodes. There were no in-hospital deaths within 30 days. Twenty-two patients did not require postoperative ventilatory support. Vital capacity decreased to 85% +/- 11% of the preoperative values, and forced expiratory volume in 1 second decreased to 82% +/- 16%. CONCLUSIONS: Thoracoscopic mediastinal lymphadenectomy is technically feasible, and its completeness is comparable to that of the open technique. The decline in pulmonary function is significantly less than that seen in our previous experience with the open technique.

Aged↗
PubMed1996

Should lung volume reduction for emphysema be unilateral or bilateral?

Both unilateral and bilateral lung volume reduction procedures are being advocated for treatment of severe, generalized emphysema. We analyzed the results of 166 consecutive patients who underwent unilateral (n = 87) or bilateral (n = 79) thoracoscopic stapled lung volume reductions to help define the role for these procedures. There was no statistically significant difference in the operative mortality (3.5% vs 2.5%), mean length of stay (11.4 +/- 1 vs 10.9 +/- 1 days), or morbidity for the unilateral and bilateral groups, respectively (p not significant for all variables). Oxygen dependence was eliminated in 18 (36%) of 50 patients who had unilateral procedures and 30 (68%) of 44 of those who had bilateral procedures (p < 0.01). Prednisone was eliminated for 38 (54%) of 51 unilateral-procedure patients, compared with 30 (85%) of 35 bilateral-procedure patients (p = 0.02). Overall, bilateral procedures produced a mean improvement in the forced expiratory volume in 1 second (FEV1) of 57%, compared with 31% for unilateral reduction procedures (p < 0.01). Our bilateral staple procedure produced a 72.8% mean increase in the FEV1 for patients who had upper lobe emphysema. Especially compromised patients (age > or = 75, with preoperative room air Po2 < or = 50 mm Hg or FEV1 < or = 500 ml) had the same morbidity and operative mortality with unilateral or bilateral procedures, but they had a higher 1-year mortality (17% vs 5%), primarily because of respiratory failure after the unilateral operation (p < .001). Although unilateral staple lung volume reduction may produce an excellent result in a given patient, the bilateral procedure appears to be the procedure of choice, because it provides better overall results at no increased morbidity or mortality compared with the unilateral procedure. The results of bilateral staple lung volume reduction by thoracoscopy appear to be comparable to those of median sternotomy.

Aged↗
PubMed1996

Combined thoracoscopic/laparoscopic staging of esophageal cancer.

Unlike mediastinoscopy in lung cancer, there exists no standard minimally invasive test to stage esophageal cancer. If it were possible to obtain exact preoperative staging in esophageal cancer, patients could be separated prospectively to receive neoadjuvant therapy appropriately. We studied the feasibility and efficacy of thoracoscopic and laparoscopic lymph node staging in esophageal cancer. Thoracoscopic staging was performed in 45 patients with biopsy-proven carcinoma of the esophagus. Laparoscopic staging was done in the last 19 patients. Thoracoscopic staging was aborted in three patients because of adhesions. Thoracic lymph node stage was N0 in 39 patients and N1 in three; celiac lymph nodes were normal in 13 and diseased in six. Esophageal resection was performed in 30 patients after thoracoscopic staging; 17 of these underwent laparoscopic staging. Thoracoscopic staging showed N0 lymph node status in 28 patients and N1 in two patients. Two of the 28 patients (7%) with N0 disease were found at resection to have paraesophageal lymph node involvement (N1); thus the disease was understaged by thoracoscopic staging. Thoracoscopic staging was accurate in detecting the presence of diseased thoracic lymph nodes in 28 of 30 cases (93%). Laparoscopic staging detected normal celiac nodes in 12 patients and diseased lymph nodes in five patients. After esophagectomy, the final pathology report in the 12 patients with N0 disease was N0 in 11 and diseased lymph nodes in one patient. Thus laparoscopic staging was accurate in detecting lymph node metastases in 16 of 17 patients (94%). Thoracoscopic and laparoscopic staging are more accurate than existing staging methods. Six of 19 patients in whom laparoscopic staging was used had unsuspected celiac axis lymph node involvement that had been missed by standard noninvasive techniques. One of three patients with thoracic lymph nodes and three of six with celiac lymph nodes were downstaged after preoperative chemotherapy/radiotherapy. The role of thoracoscopy and laparoscopy in staging esophageal cancer should be further evaluated in a multiinstitutional trial.

Adenocarcinoma↗
PubMed1996

Functional effects of decortication after penetrating war injuries to the chest.

Decortication was performed in 32 persons with penetrating war injuries to the chest. The indications were acute and chronic post-traumatic empyema, incompletely evacuated hemothorax, chylothorax, and chronic pneumothorax. Decortications were done through a thoracotomy in 29 cases and by thoracoscopy in three cases. Results of overall lung function tests and blood gas analyses were studied in all patients before operation, after immediate postoperative recovery, and 6 months after operation. Significant improvement in lung function was observed after decortication in all patients, particularly after thoracoscopic decortication. Restrictive pattern decreased moderately (p < 0.01). Blood gas analyses did not show significant changes after operation. There were no intraoperative or postoperative deaths.

Adult↗
PubMed1999

Advances in the diagnosis and treatment of thoracic trauma.

With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade or hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using beta-blocker-induced relative hypotension, is rapidly becoming the standard of care throughout the United States.

Aortic Dissection↗
PubMed1997

Perioperative management of lung volume reduction patients.

Over the last 2 to 3 years, surgical lung volume reduction via sternotomy or thoracoscopy has been widely explored as an alternative to improve dyspnea, exercise tolerance, and lung mechanics in patients with severe emphysema. In this article, the authors describe the intra- and postoperative management of patients with severe airflow obstruction who undergo this procedure. Anesthesia techniques, extubation, ventilatory management, and overall medical and surgical care are reviewed. The most common postoperative complications also are reviewed, and management of these complications is discussed.

Adult↗
PubMed2002

[Thoracocentesis for the assessment of lung cancer with pleural effusion].

OBJECTIVE: To analyze the pleural and mediastinal effect of thoracentesis tumor-positive cytology in pleural effusions (PE) detected by chest X ray of lung cancer patients. PATIENTS AND METHODS: The study was performed in patients with lung cancer for whom PE was evident in chest X ray films, who then underwent thoracentesis followed by video-assisted thoracoscopy (VAT) to evaluate direct pleural tumor infiltration, mediastinal node involvement and the existence of pleural metastasis. Patients without contraindication underwent the procedure, even if tumor positive cytology was present. When pleural metastasis was found the treatment employed was talc pleurodesis and chemotherapy. Descriptive statistics were compiled and the validity of VAT for pleural metastasis diagnosis, of thoracentesis pleural cytology to detect infiltration of the tumor-adyacent pleura, N2 disease and pleural metastasis were calculated. Survival was also analyzed. RESULTS: PE was present in 188 of 971 consecutive lung cancer patients. Seventy two PEs were visible in the chest X ray films. Volume exceeded 425 mL. Tumor positive pleural cytology was detected in 29 cases (40%). Pleural metastasis were found in 54 patients, 23 of whom had tumor positive pleural cytology. In the other 6 patients with positive cytology the primary neoplasm infiltrated the visceral pleura, completely in 5. In 4 of those 5, the mediastinal pleura was also involved. The primary tumor and diseased lymph nodes were removed from 11 patients, 3 of them with tumoral pleural cytology. Visual pleural inspection by VAT had a sensitivity of 93%, specificity of 82%, positive predicted value (PPV) of 94% and negative predicted value (NPV) of 78% for the diagnosis of pleural metastasis. Thoracentesis cytology showed a sensitivity of 43%, specificity of 67%, PPV of 79% and NPV of 28% for pleural metastasis. For the evaluation of adjacent pleura infiltration, without pleural metastasis, the sensitivity of cytology was 40%, specificity 100%, PPV 100% and NPV 25%. For mediastinal node invasion clinically evaluated, the sensitivity of cytology was 55%, specificity of 62%, PPV 18% and NPV 90%. Survival after thoracotomy was 39% after 2 years, and the median survival time was 14.5 months. In the 11 resected patients, survival was 53% at two years. The difference in survival between patients treated by thoracotomy and those treated by talc pleurodesis after VAT was significant (p < 0.01). The 3 resected patients with pleural tumor-positive cytology survived 84, 39 and 25 months. CONCLUSIONS: Nineteen percent of patients with lung cancer have PE, of which 7% can be seen in chest X ray films. In such patients the likelihood of pleural metastasis is 75%. Pleural metastasis is not necessarily present when PE cytology indicates that tumor is present. VAT can be considered the ideal technique for the assessment of direct pleural invasion by the tumor or of pleural metastasis.

Adenocarcinoma↗
PubMed1999

[The treatment of myasthenia gravis by video thoracoscopic thymectomy. The technic and the initial results].

The primary role of thymectomy for the treatment of myasthenia gravis is currently undisputed. Traditionally, the approach of choice has been sternotomy, although a transcervical route has also been advocated because of its lower rate of associated morbidity. Our department performed thymectomy using a video-assisted thoracoscopic technique in 7 patients (2 men and 5 women) between March 1993 and October 1995. The patients' mean age was 43.4 years (range 20 to 66 years). Complications were few, consisting of 2 cases of pneumothorax due to contralateral opening of the pleura, resolved by pleural drainage. No deaths occurred. Clinical results over periods of observation ranging from 14 to 44 months were excellent in 2 cases of complete remission; good in 3 patients with considerable reduction in drug requirements; and fair in 2 patients who continued to need the same doses of medication throughout the 14 months after thymectomy. The technique we propose is less aggressive than mid-sternotomy, offering incontrovertible advantages and leading to faster. No patient required assisted ventilation for longer than 4 hours and the maximum time spent in the intensive care unit was 24 hours. We therefore suggest that thymectomy to treat myasthenia gravis be performed by thoracoscopy.

Adult↗
PubMed1997

Spontaneous pneumothorax: consecutive treatment of a series of 45 cases. Preliminary results of using therapeutic videothoracoscopy.

The appearance of procedures derived from video assisted thoracoscopy (VAT) has fostered new breakthroughs in the treatment of spontaneous pneumothorax. Our early experience with a study protocol using this technique is described. Patients admitted to our hospital in 1995 with a diagnosis of spontaneous pneumothorax were enrolled consecutively. Diagnosis was based on symptoms and pneumothorax was quantified by measuring the interpleural distance observed on the chest film. The initial treatment was pleural drainage; VAT was ordered in cases of recurrence, when lung reexpansion failed or when air leakage was persistent. Forty-five cases (30 men, 15 women) are reported. Mean age was 29 years. Eleven (24%) patients had had earlier pleural drainage but were suffering recurrences. The right side was involved in 14 (54%) cases. Initial treatment was pleural drainage and in 32 cases no other treatment was given. VAT was performed on 11 patients. In 1 (9%) patient the procedure became a minithoracotomy, or video-assisted thoracoscopic surgery. In 2 patients conventional thoracotomy was performed. Mean time the procedure lasted was 80 min. Mean follow-up was 3 months. There were no recurrences among patients treated with VAT and surgery. Our initial experience demonstrates that VAT is the technique of preference for the definitive treatment of spontaneous pneumothorax. There is less postoperative pain, increased comfort, no noteworthy morbidity, shorter postoperative hospital stays and prompt return to normal activity for the patient; these advantages lead us to choose this treatment over open surgery.

Adolescent↗
PubMed1996

[Left splanchicectomy with videothoracoscopy for the control of pain in cancer of the esophagogastric union with invasion of the celiac plexus].

Blockade of the celiac plexus and the splanchnic nerves to combat abdominal pain can be achieved by percutaneous injection of local anesthetics or alcohol, or by thoracotomy. We describe the technique for performing splanchnicectomy with video-thoracoscopy in palliative surgery for cancer of the esophagogastric union, discussing the excellent results obtained immediately in 2 patients.

Aged↗
PubMed1994

[Rapid surgical exploration of the mediastinum].

This study aimed to evaluate the morbidity-mortality of surgical exploration of the mediastinum in patients with mediastinal masses or adenopathy in the context of a rapid-surgery program that has been operating over the past 8 years (1985-1993). A total of 93 mediastinal explorations have been carried out. Sixty-five involved transcervical mediastinoscopy, 20 were anterior mediastinotomies, 4 were combined procedures and 4 were video-thoracoscopies. We found 34 cases of lymphoma, 28 of metastasis of bronchopulmonary carcinoma and 16 of mediastinal-ganglionic tuberculosis; the 15 remaining cases were classified as miscellaneous. No deaths were directly related to the surgical procedures; morbidity involved 2 wound infections. Surgical exploration of the mediastinum is a safe diagnostic procedure, provided it is carried out by an experienced team, and allows care givers to take better advantage of therapeutic options with no loss of quality.

Adolescent↗
PubMed1996

Instrumentation and techniques for laparoscopic and thoracoscopic surgery in the horse.

Equine surgery continues to benefit from advances in laparoscopic techniques. Descriptions of the normal anatomy of the standing horse and advances in instrumentation have improved our ability to perform laparoscopic surgery in both standing and dorsally recumbent horses. The common uses for laparoscopy are diagnostic laparoscopy, cryptorchidectomy, ovariectomy, and diagnostic thoracoscopy. Other reported uses include inguinal hernia repair, ruptured bladder repair, and ventral colopexy.

Animals↗
PubMed2005

[Pleural effusion following hepatic radiofrequency].

INTRODUCTION: Surgery is the treatment of choice for primary or secondary hepatic tumours. If surgery is contra-indicated radiofrequency offers an alternative treatment capable of destroying tumours small in size and/or number. It is undertaken percutaneously, during laparotomy or endoscopically. Respiratory physicians should be familiar with certain complications. CASE REPORTS: We report two cases of pleurisy following hepatic radiofrequency. The effusions were diagnosed 15 days and one month after radiofrequency treatment for liver metastases from colonic carcinoma. The effusions were exudative and predominantly lymphocytic. The first effusion required thoracoscopy to establish the diagnosis; the second dried up following 5 pleural aspirations. CONCLUSION: Post radiofrequency pleurisy may develop late and present problems in diagnosis and treatment.

Aged↗
PubMed1996

Reexpansion pulmonary edema occurring after thoracoscopic drainage of a pleural effusion.

Video assisted thoracoscopic drainage and tale pleurodesis was used to treat a recurrent pleural effusion in a 60 year-old woman undergoing major gynecologic surgery. She developed reexpansion pulmonary edema immediately following surgery. Several important risk factors that were present in this patient are discussed. In addition to almost, complete collapse of the underlying lung for several weeks, thoracoscopy resulted in manipulations and rapid re-inflation of the underlying lung, which further increased the risk to the patient.

Adenocarcinoma↗
PubMed1996

Pulmonary function of patients with spontaneous pneumothorax in relation to the extent of emphysema-like changes.

The aim of the present study was to analyse pulmonary function parameters of patients with spontaneous pneumothorax (SP) in relation to the extent of emphysema-like changes (ELCs). Pulmonary function tests were performed in 85 patients with unilateral SP, 6 weeks after video-assisted thoracoscopy (VAT). In 63 patients, thoracic computer tomography (CT) was obtained. An ELCs score, based on findings of CT and VAT, was used to quantify ELCs, ranging from 0 (expressing no ELCs) to 3 (expressing extensive ELCs). Emphysema-like changes were detected during VAT in 74% of patients, of which 70% were considered larger than 2 cm. An ELCs score > or = 2 was found in 27 patients. Clinical characteristics of the patients grouped according to thoracoscopical findings and ELCs score did not differ, except for age. Patients with large ELCs were significantly older than patients without ELCs or small ELCs (P = 0.0009). In patients with large ELCs and ELCs score > or = 2, increased mean percentages of predicted total lung capacity and decreased diffusing capacity (KCO) were found. None of the patients exhibited all pulmonary function criteria of emphysema, in contrast to 43% of the patients with an ELCs score > or = 2. KCO was the only pulmonary function parameter which was decreased in smokers, especially in patients with large ELCs or ELCs score > or = 2. Static lung compliance (Cstat) was the only pulmonary function parameter which was increased in patients with recurrent SP. The authors concluded that KCO is related to smoking behaviour and ELCs in patients with SP. Cstat is the only parameter which is increased in patients with recurrent SP. The discrepancy between pulmonary function and macroscopical parenchymal changes could be explained by the fact that not all patients with SP are old enough at presentation to show all signs of emphysema with pulmonary function testing. On the other hand, it might be possible that ELCs in SP cause different pulmonary function abnormalities than in centriacinar or panacinar emphysema.

Adult↗
PubMed1997

Artificial pneumothorax by the Veress cannula: efficacy and safety.

In 16 patients with pulmonary fibrosis, an artificial pneumothorax was introduced using the Veress cannula and the Saugman water manometer. Atmospheric air was introduced by fractionated insufflation to a total volume of 800 ml (median). The interpleural space was found on the first attempt, and in all cases, fractionated insufflation of atmospheric air was conducted while the intrapleural pressure was controlled with the water manometer. In one case, the procedure was stopped because of a rise in the pleural pressure after insufflation of only 50 ml air. This was undoubtedly caused by pleural adhesions not visible on chest X-ray. The main concern with air insufflation is air embolism but this was not observed clinically in any of the present cases. The patients in the present study all suffered from pulmonary fibrosis judged by clinical examination, chest X-ray and pulmonary function tests. Despite a diffusion capacity (DCO/VA) with a median value of 48% expected, the procedure was well tolerated. It has previously been shown that artificial pneumothorax preceding thoracoscopy is well tolerated due to hyperventilation, with an increase in respiratory frequency and a fall in arterial CO2 concentration (PaCO2), while pH and arterial O2 concentration (PO2) remain constant. This probably also explains the tolerance of the patients in this material. Insufflation of air as described here should be restricted to senior pulmonologists because it is an infrequent procedure. The present authors found the procedure to be uncomplicated and easy to perform with little discomfort to the patients.

Adult↗