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Bronchoscopy, thoracocentesis, and fine needle aspiration are the three most useful biopsy techniques for thoracic lesions. Minimally invasive procedures, such as mediastinoscopy and thoracoscopy, must readily be available. As biopsy techniques and the lesions to be biopsied become more complex, the surgeon should make the decision regarding the particular technique. Exploratory thoracotomy remains the ultimate thoracic biopsy.
A case of a young patient who was operated on of a large dermoid cyst of the anterior mediastinum is reported. During this procedure, a new three-dimensional imaging system was used. This case-report confirms the usefulness of thoracoscopy for benign mediastinal tumors removal and points out the benefit of three-dimensional endoscopy for dissection of tumors having complex anatomical connections.
OBJECTIVES: To describe initial experience with a new technique for obtaining lung biopsy specimens using video-thoracoscopy and Multifire Endo GIA (U.S. Surgical Corporation) stapler. DESIGN: Retrospective study. SETTING: Central hospital, Denmark. SUBJECTS: Nine patients with suspected pulmonary fibrosis. MAIN OUTCOME MEASURES: Diagnosis, morbidity, and mortality. RESULTS: The endoscopic method provided a specimen of lung tissue large enough to secure a reliable diagnosis in all cases. CONCLUSION: The thoracoscopic technique implies less surgical trauma than thoracotomy resulting in less postoperative pain and a better cosmetic result. In patients suitable for general anaesthesia the endoscopic method for obtaining lung tissue specimen seems to be the ideal method.
The aim of this work was to determine the role of video-thoracoscopy and mediastinoscopy for the diagnosis of lymph node enlargement in the mediastinum of unknown aetiology. From January 1992 to December 1993, 26 patients were seen for surgical biopsy of mediastinal lymph nodes. Relative localization and the requirement for an associated gesture determined the choice between axial mediastinoscopy, parasternal scopy and videothoracoscopy. Mediastinoscopy was performed for peritracheal or right hilar (Baréty) nodes and parasternal scopy for anterior mediastinal masses. Videothroacoscopy was performed when the lymph nodes were localized at the preceding sites or when an associated manoeuver was required. Mediastinoscopy was performed in 16 patients. Lymphorrea which subsided after 4 days occurred in one patient and the mean hospital stay was 2.6 days. Diagnosis was achieved in 15 cases. The delay from procedure to treatment was 11 days on the average. Parasternal scopy was used 3 times and gave the diagnosis in all cases. Videothoracoscopy was used for 7 patients including 2 cases with pulmonary biopsies. Diagnosis was established 7 times and the delay to treatment was 12 days. No diagnostic thoracotomie were performed during this period. When access to the mass to be biopsied is difficult with mediastinoscopy (aorto-pulmonary, subcarenal, triangular ligament) videothoracotomy can be useful. Post-operative follow-up is simple and a specific treatment can be instaured rapidly. Videothoracotomy should be an important supplementary method for mediastinoscopy and helping avoid thoracotomy.
A mediastinal thymic cyst was excised under thoracoscope in a 66 year-old man. Mass lesion was noted in the left anterior mediastinum on chest X-p during a screening examination. Based on the findings of the chest CT and MRI, the mass was diagnosed as a cyst containing low fat and low protein fluid without solid tissue. This lesion was diagnosed as a mediastinal thymic cyst. Under general anesthesia, the thoracoscopy was inserted to the left thoracic cavity. Then, the cyst was resected sharply and bluntly with pair of scissors, while electric coagulation was performed as needed. In cases of mediastinal thymic cyst, it is possible to completely resect the cyst by thoracoscopic treatment, causing minimal surgical invasiveness. Considering that a few thymic cysts are combined with malignant tumor, complete resection of the lesion is required in the treatment of thymic cyst.
Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as follows: (1) Video-assisted thoracic surgery can be as effective therapeutically as many formal thoracotomy. (2) Excellent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an excellent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visually guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also allows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest.
Surgical treatment of pericardial effusions are, in general, treated by methods using a subxiphoid or a transthoracic route. The former is criticized for the high recurrence rate, the latter for the high incidence of respiratory complications. To minimize these problems and in view of the growing enthusiasm for using minimal invasive techniques, we treated one patient with pericardial effusion by using video-assisted thoracoscopy for the creation of a pericardial window. We achieved an adequate drainage, and the postoperative pain and pulmonary dysfunction were minimal. The operative technique and pitfalls are discussed in this report. Thoracoscopic pericardial fenestration might facilitate a much less aggressive transthoracic approach to the pericardium which is of great importance, as many of these patients are already in a poor clinical condition.
BACKGROUND: Hyperhidrosis palmaris is a functionally and socially disabling problem. Thoracic sympathectomy of the T2 ganglion has proved to be the time-honored treatment modality. STUDY DESIGN: The results of this study demonstrate the effectiveness of video-assisted thoracoscope for treatment of hyperhidrosis palmaris. The possibility to apply different anesthetic techniques and to measure surface temperature change of the hand were documented as well. RESULTS: Eighty consecutive cases (159 procedures) of essential hyperhidrosis palmaris were treated by video-assisted thoracoscopic T2 sympathectomy between January 1991 and December 1992. The surgical results were classified as excellent (much improved, very dry) in 88.1 percent, good (improved, minimal wet) in 9.4 percent, and fair (slightly improved, still wet) in 2.5 percent of the patients. The postoperative complications included one prolonged air leakage, one hemothorax, two wound infections, and 15 cases of facial anhidrosis. There were no recurrent cases (mean follow-up, 14.5 months). Fifty-six patients had concomitant hyperhidrosis pedum. Interestingly enough, through unknown mechanism, 64.3 percent of the patients with concomitant hyperhidrosis pedum were cured after this procedure. CONCLUSIONS: Video-assisted thoracoscopy provides magnified surgical fields, which make thoracoscopic sympathectomy for hyperhidrosis palmaris an effective, safe, easy to use, and time-saving procedure. This technique is also excellent for teaching purposes and allows the assistant to participate in the operation.
Spontaneous pneumothorax (PNO) is usually due to rupture of a small subpleural bleb into the pleural cavity and affects mainly young men. After simple drainage, recurrence occurs in about 50% of cases. The risk of recurrence increases after each new PNO. Secondary PNO complicates an underlying pulmonary disease, especially chronic obstructive pulmonary disease with emphysema. A new form of secondary PNO has emerged in the recent years in AIDS patients with pneumocystis carinii pneumonia. We have shifted to a thoracoscopic therapy of PNO since May 1991. 25 PNO in 24 patients (1 bilateral) have been treated since that time up to April 1993. 19 PNO were primary, whereas 6 were secondary, included 3 iatrogenic PNO. Resection of the leaking parenchymal area was performed in 20 patients, and parietal partial pleurectomy was done in 20 cases. In the remaining cases, fibrin glue was applied on the lesion and in 3 cases, chemical pleurodesis was attempted using silver nitrate or talc. 1 AIDS patient died of ARDS. 3 patients had recurrent PNO and had thoracotomy without complication. 21 patients did well. Partial PNO recurred in one of them 4 months later, and was treated by simple needle aspiration. Thoracoscopy is a useful method to treat recurrent or persistent spontaneous PNO. After only 25 cases, our success rate in primary PNO is 90%. There should be a learning curve. On the basis of our experience, we believe that recognition of the lesion and its resection as well as apical parietal pleurectomy are necessary to obtain good results and a low recurrence rate.
The objective of this follow-up study was to evaluate the success rate of different therapy procedures in spontaneous pneumothorax. In order to achieve comparable conditions the study was restricted to those patients who were treated because of a first episode (n = 96) in the time between January 1978 and December 1987. Seventy-one were males and 25 females, ratio 3:1. The right side to left side ratio was 3:2. Both sides were affected in 11% (n = 11). All patients received an intercostal tube drainage with a permanent suction. In case of treatment failure thoracoscopy, pleurodesis or an operation were performed. The follow-up investigations was performed in January 1990 thus to further evaluate the outcome of 79 patients (82%) after 2 to 12 years after treatment. Among the patients, 33 patients presented a persistence or an early recurrence, 26 of them were operated during their first stay in hospital. A further 25 patients presented a late recurrence, of whom 14 underwent a later thoracotomy. Consequently the drainage therapy had a failure rate of 61% (n = 58). The frequency of operation was 42% (n = 40). The results after thoracotomy (n = 26) were as follows: slight complications, which did not require surgical treatment occurred in 8% (n = 2). The long-term results after surgical intervention (lung apex resection and/or parietal pleurectomy) were excellent concerning the rate of late recurrences (0% within the follow-up group) and the general condition (96% free or almost free of symptoms) regardless the method of operation.(ABSTRACT TRUNCATED AT 250 WORDS)
The decision for surgical measures in bronchial carcinoma is mainly based on the preoperative assessment of the presumed tumour extent and cell type, as well as cardiopulmonary function. Bronchoscopy, as an obligatory procedure, allows a definite diagnosis in most of the cases, definition of the most proximal tumour extension and exclusion of bilateral endobronchial disease. Transbronchial needle aspiration can provide important information on lymph node involvement, although mediastinoscopy has the highest diagnostic yield and remains the standard procedure for lymph node staging. Thoracoscopy, providing a much higher sensitivity than thoracentesis, enables differentiation between malignant or para-malignant pleural effusion in almost all of the cases. Thus, endoscopy alone often demonstrates unresectability.
Surgery of the intrathoracic organs may be performed without compromise of respiratory mechanics considering minimally invasive principles. An analysis of our experience of 373 thoracoscopic interventions reveals that the diverse procedures performed on the pleura (pleurectomy, pleurodesis), on the lung (wedge resection, fistula closure, ligature of parenchymatous leaks) and on other definec anatomical structures such as the sympathetic nerve or the thoracic duct, are effective in the therapy of intrathoracic disease. The most important pathological conditions which may be treated by thoracoscopy are listed. The range of complications (7%) and their causes are discussed. Current developments and innovations are summarized by a short review of the literature.
His extensive developmental and clinical work made Raimund Wittmoser a major trailblazer in endoscopic surgery from the 1950s on. His single-puncture technique for operative thoracoscopy permitted surgical interventions of peerless quality on the sympathetic and vagal nerves. His basic surgical principle was to achieve the greatest possible selectivity by a segmental approach to the sympathetic rami communicantes or the individual branches of the vagus nerve. Besides his extraordinary surgical skills, his particular achievement was the development of new instrumental and ancillary technologies for endoscopic surgery. In addition to the development of new endoscopes and imaging systems, his pressure-regulated CO2 insufflation system and low frequency cautery technique had major impact on the further development of endoscopic surgery. Finally, Wittmoser's surgical interventions in the autonomic nervous system were of outstanding quality and set standards still observed by thoracoscopic surgeons today.
Forty two cases of pleural mesothelioma were reported. Macroscopic findings showed that 10 were localized and 32 diffuse. Histological diagnosis revealed 4 benign fibrous tumors and 38 malignant mesothelioma (epithelial type in 25, sarcomatous in 6, and mixed in 7). The main clinical manifestations of malignant mesothelioma were chest pain and dyspnea. The most frequent chest radiographic signs were nodular pleural thickening, irregular thickening of interlobar fissures, a dominant mass and pleural effusion. This disease was usually misdiagnosed as tuberculous pleurisy, lung cancer and metastatic pleural tumors. X-ray examination and CT scan were helpful in the diagnosis of the disease. Thoracoscopy is currently a suitable diagnostic method for pleural mesothelioma. Surgical management and chemotherapy were carried out in 31 cases. 3-year survival rate in 38 patients with malignant mesothelioma was 8.8%. Resection was considered as the treatment of choice for localized mesothelioma. Thoracoscopic talc poudrage followed by chemotherapy was used for on diffuse malignant mesothelioma with pleural effusion to improve survival and prevent recurrent effusion. The histologic type, stage and treatment were identified as significant prognostic factors.
The immediate effects and long-term results are reported of thoracoscopic pleurodesis in 225 patients (158 men, 67 women) treated for persistent or recurrent spontaneous pneumothorax. The procedure was performed by combined local and neurolept analgesia with direct visual exploration of the pleural space through a rigid thoracoscope. The technique included electrocoagulation of small pleural blebs, followed by regional application of fibrin and insufflation of talc powder. The main indications were a first event which persisted more than 7 days despite chest-tube suction drainage in 27% (n = 61) or a recurrent event in 73% (n = 164). The procedure provided primary success in 96.4% of the patients. Only 8 patients (3.6%) required surgical intervention including parietal pleurectomy. Perioperative complications were pharmacologically induced respiratory failure (n = 5), generalized subcutaneous emphysema (n = 8), bleeding by cutting adhesions (n = 5) and Horner's syndrome (n = 2). However, no fatal complications occurred which could be ascribed to the procedure and all patients were discharged from the hospital after an average of 12.3 days except one who died of pulmonary embolism 5 days after thoracoscopy. Long-term follow-up over a mean period of 4.1 years revealed an ipsilateral recurrence rate of 10.2% (n = 24), 16% of the patients complained of sporadic pains at the site of insertion, 51% still had diffuse thoracic pains and 2.4% reported occasional attacks of dyspnea. Spirometric lung function tests showed normal values in 89%. The immediate and longterm results show thoracoscopic pleurodesis with fibrin and talcum to be a safe and effective method for treatment of patients with persistent or recurrent pneumothorax.
Surgical thoracoscopy is in its first stage of development. However indications are expanding rapidly. This work is a review of the conditions of surgical endoscopy of the chest, the equipment currently available and the main indications. Some of these indications are already accepted. For other indications, further evaluation is needed. Many experimental works as well as clinical studies are required in order to make progress.
Since 1980, we have collected fourteen cases of mesothelioma induced by environmental exposure to asbestos, going back to childhood in patients from north-east Corsica, in a region which was remote from the asbestos mine of Canari. There were eight men and six women with a mean age of 69.5 +/- 4 years. Six patients presented with bilateral calcified pleural plaques as evidence of environmental exposure. The mineral analysis carried out on five patients (four had thoracoscopies and one an alveolar lavage), showed a moderate deposit of chrysotile (0.3 to 3.4 x 10(6) fibres per gram of dry tissue), and elevated level of tremolite (1.4 to 62 x 10(6) fibres/g). The ambient dosage of asbestos has confirmed the existence of environmental pollution by chrysotile fibres and above all by tremolite. In addition, the same type of fibres have been identified in the parietal pleural of animals subjected to the same risk. In this region, the risk is estimated, on the basis of our results, as 10 cases of mesothelioma per 100,000 inhabitants per year.
We present the initial results fo thoracoscopic resection of pulmonary nodules, based on a report of 23 patients. The resection was performed through a sole thoracoscopy in 12 cases, but was associated with a mini-incision in 11 cases. In 4 cases, the procedure had to be converted to thoractomy. We discuss the problems encountered and the indications of the technique.