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PubMed2004

Thoracoscopic enucleation of a giant submucosal tumor of the esophagus.

Since the introduction of thoracoscopy in the surgical field, many thoracic interventions have been considered feasible via thoracoscopic route. The authors reported a case of thoracoscopic enucleation of a giant esophageal submucosal tumor (8.5 cm in diameter) situated along the left side of the midesophagus. Histopathologic evaluation revealed a gastrointestinal stromal tumor (GIST). Postoperative period was uneventful and the patient was discharged on the eighth postoperative day. Given the well-known advantages of minimally invasive surgery, we assume that the removal of esophageal submucosal tumors can first be attempted by thoracoscopic approach, even if the tumor is of a big size. In cases of histopathologically unknown tumors preoperatively, definitive examination of the complete specimen provides the basis for further therapeutic decisions.

Biopsy, Needle↗
PubMed2005

Prospective evaluation of 50 consecutive scoliosis patients surgically treated with thoracoscopic anterior instrumentation.

STUDY DESIGN: Prospective, consecutive, single-surgeon case series of patients treated for scoliosis with thoracoscopic anterior spinal instrumentation. BACKGROUND: A thoracoscopic approach for insertion of anterior instrumentation has been developed in the past 10 years, which obviates many of the disadvantages of the open anterior thoracic approach. The morbidity associated with a thoracoscopy is limited because of the minimal skin and chest wall dissection required with this method. PURPOSE: The purpose of this evaluation is to report a single surgeon's experience with an initial series of 50 patients. The goal is to report the outcomes with regards to the radiographic findings, pulmonary function, and the SRS Outcomes Instrument, as well as a review of the perioperative data and complications. METHODS: The primary author's initial 50 thoracoscopic anterior spinal instrumentation patients were consecutively collected. Data collection included demographics, such as age, gender, and diagnosis. Data regarding the surgical procedure included the operative time, intraoperative estimated blood loss, as well as the number of levels instrumented anteriorly. In the perioperative hospital period, data were collected with regard to the length of the hospital stay, the number of days in the ICU, the number of days of ventilator support, and the number of days after surgery when conversion from IV to PO pain medication occurred. Radiographic data were obtained systematically on each patient and measured by authors other than the surgeon. The SRS 22 and/or 24 Outcomes Questionnaire and pulmonary function tests were administered to patients at similar intervals. RESULTS: The series consisted of 44 females and 6 males with a mean age of 14 years (range, 9-48 years). Forty-five of the 50 patients were available for clinical and radiographic evaluation at greater than or equal to 2 years after surgery. The average length of follow-up for these 45 patients was 33 months (range, 2-5 years). The mean operative time for the procedure was 350 +/- 50 minutes and ranged from 265 to 528 minutes. The estimated intraoperative blood loss averaged 431 +/- 273 mL (range, 75-1,400 mL). Normalizing the operative time and estimated blood loss based on the number of levels treated resulted in an average operative time per level of 48 +/- 6 minutes per level and an estimated intraoperative blood loss per level of 60 +/- 37 mL per level. The preoperative thoracic Cobb averaged 53 degrees +/- 9 degrees (range, 40 degrees-80 degrees). At most recent follow-up (> or = 2 years), the thoracic Cobb averaged 24 degrees +/- 7 degrees. Implant failure occurred in 3 cases. CONCLUSION: Thoracoscopic anterior instrumentation for adolescent idiopathic scoliosis is a viable surgical option. The outcomes of this consecutive series of patients is comparable to prior open and endoscopic series presented in the literature. The technical challenges of this operation are evident in the learning curve effect, which has been demonstrated.

Adolescent↗
PubMed2005

Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series.

OBJECTIVE: Malignant pleural mesothelioma is a fatal disease with a mean life expectancy of 6-12 months. Since 1982, we have performed thoracoscopic talc poudrage (TTP) as a primary therapy in mesothelioma patients presenting with pleural effusion. As the survival data for our patients surpassed that of many published series, the patient data was analyzed to determine whether talc poudrage can be considered as a contemporary palliative option. METHODOLOGY: We reviewed all 26 patients with a final diagnosis of malignant pleural mesothelioma from our prospective database of 228 consecutive patients who received thoracoscopy from the same physician for recurrent symptomatic pleural effusion. Patients were followed up until their death. RESULTS: Mean survival after TTP was 23.8 +/- 16.3 months (median 19.4, range 2.9-68). Pleurodesis palliated dyspnoea in all patients. No perioperative deaths and one postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 +/- 2.7 days. CONCLUSION: TTP remains a safe, low-morbidity, inexpensive primary palliative treatment option for malignant pleural mesothelioma and a valid control arm option for therapeutic trials. TTP is ideal for patients who wish to avoid thoracotomy, long hospital stays and morbidity from multimodality therapy. Prospective randomized studies are needed to compare quality of life and survival after talc poudrage and other therapies.

Aged↗
PubMed2001

Epiphrenic diverticula: minimal invasive approach and repair in five patients.

Epiphrenic esophageal diverticula are rare and often asymptomatic. If surgery is mandatory, a thoracotomy is used to resect the diverticulum. The results of a minimal invasive approach and repair in five patients are presented. These patients, who all presented with an epiphrenic diverticulum, were evaluated using barium swallow study, esophagoscopy, and manometry. The diverticula were approached by thoracoscopy in all patients and a description of the surgical technique is given. The diverticula were resected using a right-sided approach in four patients. One patient with a diverticulum in the distal esophagus required conversion to laparoscopy. A myotomy was performed in two patients because of high pressures in the lower esophageal sphincter. The postoperative course was uncomplicated in four patients. One patient with Ehlers-Danlos disease had a complicated course owing to leakage, resulting in two re-operations by means of thoracotomy. There was no mortality. The minimal invasive approach of epiphrenic diverticula is feasible. The long-term results are awaited.

Diverticulum, Esophageal↗
PubMed2003

Mediastinal bronchial artery aneurysm with hematemesis.

Mediastinal bronchial artery aneurysm is a rare condition which can lead to potentially fatal hemorrhage. In most cases it presents respiratory symptoms due to rupture into pleural parenchyma. But when it develops mediodorsally and compresses the esophagus, it may cause dysphagia or hematemesis. Here we report a case of mediastinal bronchial artery aneurysm which presented with hematemesis. Computed tomography and endoscopic ultrasound showed what seemed to be a submucosal tumor on the esophagus. We were able to correctly diagnose the aneurysm using magnetic resonance imaging and probe thoracoscopy, and were able to successfully treat with transluminal artery embolization.

Aneurysm, Ruptured↗
PubMed1994

One hundred and sixty-three consecutive video thoracoscopic procedures: the Hong Kong experience.

Video-assisted thoracoscopy (VAT) offers a new approach to the diagnosis and treatment of many thoracic conditions. From September 1992 to August 1993, a total of 163 VAT procedures were successfully performed on 108 patients (87 male, 21 female; age range from 12 to 77) which consisted of 42 bleb eliminations and 64 mechanical pleurodesis for spontaneous pneumothorax, 11 wedge resections for pulmonary nodules, three wedge biopsies for diffuse pulmonary infiltrate, four thoracic sympathectomies, resections of two mediastinal masses, three pericardial windows, 10 guided pleural biopsies for undiagnosed effusions, six guided drainage of empyema and haemothorax, 16 staging of intrathoracic tumours and two explorations for penetrating thoracic trauma. There was no procedure-related mortality. Complications included one recurrence for spontaneous pneumothorax, one re-exploration for bleeding (also by VAT approach), one wound infection, and six persistent air leaks for more than 10 days. The median duration of postoperative chest tube drainage was 2 days and the median hospital stay was 4 days. It was concluded that VAT is a safe and effective approach in thoracic surgery and with further refinement in instrumentation even more procedures will be technically feasible. The long-term results of VAT are being awaited in order to define its true merits in thoracic surgery.

Adolescent↗
PubMed1995

Thoracoscopic management of pleural effusions revisited.

Pleural effusion is a commonly encountered clinical condition. We report our experience with video assisted thoracoscopic surgery (VATS) in the management of pleural effusions in three groups of patients: (1) Patients with cryptogenic pleural effusions for diagnosis; (2) patients with established malignant effusions for talc insufflation and limited decortication; and (3) patients with early empyema for debridement and drainage. From September 1992 to March 1994, we have successfully managed 28 patients with pleural effusions (12 males, 16 females; age ranged from 22 days to 73 years). Management consisted of 16 diagnostic thoracoscopies with guided pleural biopsies, seven limited decortications for trapped lungs, 12 talc insufflation for recurrent symptomatic malignant effusions and debridement and drainage of five empyemata. There was no mortality or intra-operative complications. The procedure was tolerated well by all patients. The mean duration of chest drainage and hospital stay were 1.2 and 2.8 days for group 1 patients, 4.5 and 6.4 days for group 2, and 5.6 and 7.1 days for group 3. Specific histological diagnosis was obtained in all but two patients (88%). Thoracoscopic talc insufflation was successful in 92% of cases at mean follow up of 8 months. Thoracoscopic debridement and drainage of empyema resulted in rapid resolution of sepsis in all cases. Advances in video camera technology and instrumentation have allowed more therapeutic manoeuvres to be carried out. We conclude that VATS is a safe and effective way of managing selected patients with pleural effusions.

Adult↗
PubMed1998

Laparoscopy in the management of diaphragmatic rupture due to blunt trauma.

BACKGROUND: Traumatic diaphragmatic rupture remains a diagnostic challenge often unrecognized until laparotomy in over 40% of patients and the diagnosis is delayed in a further 15%. This report describes four patients diagnosed at laparoscopy with a ruptured diaphragm. METHODS: One patient had a left diaphragmatic rupture amenable to laparoscopic repair in the emergency setting. Three patients underwent laparoscopy 2, 7 and 10 days after injury which revealed two right-sided and one extensive left-sided rupture, respectively; each required open repair. RESULTS: While laparoscopy is an excellent diagnostic tool, particularly in the delayed setting, repair is not possible for right-sided ruptures because of the liver bulk. CONCLUSIONS: Thoracoscopy in the instance of delayed presentation may offer the best chance for minimal-access diagnosis and treatment when there is suspicion of a right-sided diaphragmatic rupture.

Adolescent↗
PubMedDate not supplied

Epicardial left ventricular lead placement for cardiac resynchronization therapy following failed coronary sinus approach.

Outcomes of surgical left ventricular (LV) lead placement in patients with failing percutaneous cardiac resynchronization therapy (CRT) are not well defined. The authors reviewed all primary epicardial LV lead placements at their institution to identify patient population, perioperative course, and structural and functional outcomes, and compared this group with patients who had successful percutaneous CRT. Fourteen patients (11%) required epicardial LV lead placement via left thoracotomy or thoracoscopy with mean intensive care unit stay of 2.1 days and inotrope use in 38%. Complications included ventricular fibrillatory arrest, stroke, hypotension, and major bleeding, but there was no difference in 90-day survival between epicardial and percutaneous CRT lead placement. In survivors, New York Heart Association class improved from 3.0 to 2.3 (P=.008) without a change in ejection fraction or severity of mitral regurgitation. Thus, in patients with unsuccessful percutaneous CRT, epicardial LV lead placement is associated with perioperative morbidity, but with subsequent improvement in functional status without excess mortality.

Aged↗
PubMedDate not supplied

The efficacy of mechanical abrasion and talc slurry as methods of pleurodesis in normal dogs.

OBJECTIVE: To determine the efficacy of mechanical abrasion and talc slurry as methods for pleurodesis in normal dogs. STUDY DESIGN: Experimental study. ANIMALS OR SAMPLE POPULATION: Ten normal beagle dogs. METHODS: Group I dogs had mechanical abrasion (MA) of the pulmonary and costal pleurae performed in one hemithorax with a dry gauze sponge with a median sternotomy approach. Group II dogs had 100 mL of a 1 g talc slurry (TS) administered into one hemithorax through a tube thoracostomy. Administration of the TS was visualized by using video thoracoscopy. All dogs were evaluated at 2, 10, 20, and 30 days postoperatively by means of thoracic radiography and ultrasonographic thoracic wall measurement. The dogs were euthanatized 30 days postoperatively and a gross necropsy was performed. Hemithoraces were assigned a pleurodesis score (0-4) and an obliteration grade (0-6). Tissues were collected for histopathologic examination of pulmonary pleura, costal pleura, and pleural adhesions. Pulmonary and costal pleurae were graded for the degree of fibrosis (0-4). RESULTS: Obliteration grade and costal pleural fibrosis score were significantly higher for the treated sides in the MA dogs compared with the TS dogs. MA Dogs: Mechanical abrasion dogs had pleurodesis, obliteration, and pleural fibrosis scores that were greater on the treated side than the untreated side, however, the differences were not statistically significant. Only two MA dogs had firm adhesion of the pulmonary pleura to the costal pleura in portions of the cranial and middle lung lobes in the treated hemithorax. Thoracic wall surface area covered with adhesions was 15% and 21% in each of these two dogs. The median pulmonary pleural fibrosis score of all MA dogs for the treated hemithorax was 3 compared to 0 on the untreated side. TS Dogs: There was no statistical difference for pleurodesis scores and obliteration grades between the treated and untreated sides. No dogs showed evidence of pulmonary to costal pleural adhesions. Histopathology showed talc crossover into the untreated side in all five dogs. Median pulmonary fibrosis score of the treated hemithorax was 1 compared with 0 on the untreated side. CONCLUSIONS: Neither method of pleurodesis produced sufficient pleural adhesions to obliterate the pleural space. It is possible that the degree of pulmonary pleural fibrosis present in MA dogs may be sufficient to limit air leakage from pulmonary blebs and bullae resulting in successful treatment of spontaneous pneumothorax.

Animals↗
PubMed2006

Hemodynamic effects of interpleural lidocaine and bupivacaine combination in anesthetized dogs with and without an open pericardium.

OBJECTIVE: To identify dysrhythmias and hemodynamic changes after lidocaine and bupivacaine infusion into the interpleural space with an open pericardium. STUDY DESIGN: Experimental study. ANIMALS: Six adult dogs. METHODS: Systemic arterial pressure and electrocardiogram were recorded. A 7.5 Fr Swan-Ganz catheter was advanced to the level of the main pulmonary artery to record pulmonary arterial pressure. Cardiac output was measured by a thermodilution technique. A pericardial window (PW) was performed in 3 dogs using thoracoscopy. Hemodynamic variables were recorded before and 15 minutes after injection of lidocaine (1.5 mg/kg) and bupivacaine (1.5 mg/kg) into the pleural space in the control group and in the pericardial space for the PW group. A randomized-block ANOVA for repeated measures was used to evaluate the effect of local anesthetic administration on hemodynamic and electrophysiologic variables in dogs with a pericardectomy. RESULTS: Each dog maintained sinus rhythm. Infusion of local anesthetic induced a significant increase in right ventricular diastolic pressure (P = .002) and a significant decrease in stroke volume (P = .047) in both groups; however, the effects were not significantly different between groups. CONCLUSIONS: Infusion of lidocaine and bupivacaine, either intrapleural or in the pericardial space, had a mild detrimental effect on cardiac output. CLINICAL RELEVANCE: Intrapleural administration of lidocaine and bupivacaine at a therapeutic dose can be used safely in healthy dogs with a pericardectomy.

Anesthesia, General↗
PubMed1993

Video-assisted thoracoscopic division of a vascular ring in an infant: a new operative technique.

We report the first successful use of thoracoscopy and video-assisted thoracic surgery (TVATS) techniques to relieve extrinsic tracheoesophageal compression produced by a vascular ring. The patient was a 3-month-old infant with postprandial regurgitation and a diagnosis of double aortic arch. After an uncomplicated operation and recovery, the infant was discharged on the second postoperative day. Refinement of technique and instrumentation may allow wider application of video-assisted thoracoscopic techniques in pediatric patients.

Aorta, Thoracic↗
PubMed1995

Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy.

The benefit of internal mammary artery (IMA) grafting as a long-lasting intervention for coronary artery disease is well recognized. However, largely because they are less invasive, catheter based alternatives are frequently chosen, particularly to treat single or double vessel disease. To retain the advantages of the IMA graft, and to offset the invasiveness of conventional coronary artery bypass grafting, we developed a new minimally invasive method using an anterior mediastinotomy for treating left anterior descending (LAD) or right coronary artery disease, or both. Feasibility studies using 16 pigs and a human cadaver led to approval by the Institutional Review Board for use of this procedure to treat six patients (four men, two women; mean age, 63.8 +/- 13.6 [SD] yrs) who granted informed consent. Pedicle dissection of the IMA, using video assisted thoracoscopy if necessary, was made through a 2- to 3-inch horizontal anterior mediastinotomy. The underlying LAD artery was grafted during femoral vessel cardiopulmonary bypass, with cooling to 30 degrees C, induced ventricular fibrillation, and left ventricular venting if required. Transesophageal echocardiography performed after bypass showed that two patients maintained normal wall motion and four had improvement from the original impairment. One patient suffered a recurrence of angina 4 weeks after the procedure; recatheterization showed an acutely angled IMA, subsequently corrected by balloon angioplasty. The results of follow-up dobutamine echocardiographic stress tests were negative in all patients. With this minimally invasive approach, the procedure should provide the benefits of IMA grafting with shorter hospital stay, more rapid recovery, and less overall cost.

Aged↗
PubMedDate not supplied

A xiphoid approach for minimally invasive coronary artery bypass surgery.

BACKGROUND: The premise for adopting minimally invasive cardiac surgery techniques for myocardial revascularization is to reduce the patient's morbidity without compromising the efficacy of conventional coronary artery bypass. However, opening the pleura has been a limitation of using these approaches. AIM: We used the xiphoid approach as an alternative to opening the pleura and to minimize pain after minimally invasive coronary artery bypass surgery. METHODS: We review our surgical experience in 55 patients who underwent minimally invasive direct coronary artery bypass (MIDCAB) surgery through a xiphoid approach between October 1997 and August 1999. Thoracoscopy (n = 31) or direct vision (n = 24) were used for internal mammary artery (IMA) harvesting. Mean patient age was 67 +/- 10 years and 65% were men. The mean Parsonnet score was 23 +/- 10. Performed anastomoses included left IMA (LIMA) to the left anterior descending (LAD) artery (n = 53), LIMA-to-LAD and saphenous vein graft from the LIMA to the right coronary artery (n = 1), and LIMA-to-LAD and right IMA (RIMA) to right coronary artery (n = 1). RESULTS: Postoperative complications included atrial fibrillation (12%), acute noninfectious pericarditis (12%), and acute renal failure (5%). Mean postoperative length of stay was 4 +/- 2 days. Angiography was performed in 16 patients and demonstrated excellent patency of the anastomoses. There was no operative mortality. Actuarial survival was 98% in a mean follow-up period of 11 +/- 5 months. CONCLUSIONS: Minimally invasive coronary artery bypass can be performed safely through a xiphoid approach with low morbidity, mortality, and a relatively short hospital stay.

Aged↗
PubMed1985

Thoracoscopic, histological, and clinical findings in nine case of rheumatoid pleural effusion.

A characteristic thoracoscopic picture of a granular parietal pleural surface was found in nine patients with rheumatoid pleurisy. Characteristic changes could be identified histopathologically in material obtained by biopsy. The rheumatoid pleural effusion resolved within an average of 14 months and no serious complications developed after the pleurisy. It is concluded that in rheumatoid pleural effusion a positive diagnosis can be made by thoracoscopy, preferably supported by the identification of microscopic structural changes in the parietal pleura.

Adult↗
PubMed1989

Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis.

From 1978 to 1985 96 patients with their first spontaneous pneumothorax were randomised into three groups, receiving either treatment with simple drainage (34 patients), drainage with tetracycline pleurodesis (33 patients), or drainage with talc pleurodesis (29 patients). There were 58 men and 38 women, aged 18-88 years. There was no significant difference between the three groups in the mean time in hospital or the period for which the drains were retained. The incidence of infection, persistent pneumothorax, and relapse while in hospital was also similar for the three groups. At follow-up in 1987-89 patients could be accounted for, with an average follow-up period of 4.6 years. The incidence of recurrence was 36% in the simple drainage group, 13% in the tetracycline pleurodesis group, and 8% in the talc pleurodesis group. The difference between the talc and simple drainage groups was significant. None of the methods caused severe short or long term side effects or changes in the follow-up chest radiograph. Thoracoscopy, performed on admission in 85 patients, showed normal appearances in 73 patients and small cysts in 12. The thoracoscopic findings were of no value in predicting recurrence. Talc pleurodesis resulted in a significantly lower recurrence rate than simple drainage, tetracycline pleurodesis having intermediate efficacy.

Adolescent↗
PubMed1992

Endoscopy assisted microthoracotomy: initial experience.

BACKGROUND: Although thoracoscopy has been used for diagnostic and minor therapeutic procedures for many years, there have been few reports of its use in performing major intrathoracic procedures, which have traditionally required formal thoracotomy. METHODS: Twenty one patients (M:F 1.2:1; mean (SD) age 47.1 (18.8), range 17-75 years) underwent endoscopic intrathoracic surgery. Eight had unidentified peripheral masses on the chest radiograph, eight required lung biopsy, and five had recurrent or persisting pneumothoraces. Under general anaesthesia a laparoscope attached to a video monitor was introduced into the chest. One or two additional stab incisions were made as needed for the introduction of standard surgical or endoscopic instruments and staplers. RESULTS: There were no complications or deaths, though one patient developed a second pneumothorax seven days after endoscopic pleurectomy, necessitating open pleurodesis. All patients were discharged home from two to six days after surgery (mean (SD) 3.7 (1.2) days). CONCLUSION: Endoscopic thoracic surgery is a safe and useful technique for certain cases. It merits further investigation and assessment.

Adolescent↗