Comparison of open and thoracoscopic bilateral volume reduction surgery: complications analysis

BACKGROUND: The effectiveness of lung volume reduction for the treatment of patients with emphysema is well established, but data about the surgical approach, the postoperative management, and complications are limited. We report a comparison of patients undergoing bilateral lung volume reduction (BLVRS) via median sternotomy and thoracoscopic techniques with emphasis on hospital course and complications. METHODS: All patients undergoing BLVRS at Hospital of University of Pennsylvania were analyzed for mortality and morbidity, using a combination of prospective data analysis and retrospective chart review. RESULTS: Patients undergoing BLVRS via median sternotomy were older than those undergoing video-assisted thoracoscopic surgery (VATS) procedures (63.9+/-6.89 vs 59.3+/-9.4 years, p = 0.005). Operating time was longer for the VATS procedure (147 versus 129 minutes, p = 0.006) while estimated blood less was greater for median sternotomy (209 versus 82 L, p = 0.0000017). Significant differences were found in intensive care unit stay, days intubated, life-threatening complications, respiratory complications, requirement for tracheostomy, and death that favored VATS BLVRS. When only later cohorts of patients were compared, more life-threatening complications and deaths were found in patients undergoing BLVRS by median sternotomy. There were no differences between early and late median sternotomy BLVRS patients. Twenty-six percent of the lethal complications in median sternotomy BLVRS patients were bowel perforations, equally divided between duodenal ulcers and colons. CONCLUSIONS: Managing patients after BLVRS remains complex. Bilateral video-assisted volume reduction offers equivalent functional outcome with potentially decreased morbidity and mortality. Gastrointestinal perforations can complicate the management of these patients.     

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.     

T cell responses and viral escape

OBJECTIVE: Median sternotomy was performed by 2 different techniques in order to determine whether there was a difference in the incidence of inadvertent pleural entry. EXPERIMENTAL DESIGN: Patients were prospectively evaluated and reviewed at a mean follow-up interval of 8.2 months. PATIENTS AND METHODS: Ninety five consecutive patients underwent primary sternotomy at a single tertiary referral center. MEASURES: Planned outcome measures included, incidence of pleural entry, length of hospitalization, and chest tube site related postoperative morbidity. RESULTS: Group 1 (n=49) had sternotomy undertaken from the sternal notch proceeding downwards. Group 2 (n=46) underwent sternotomy performed from the xiphoid upwards. Mediastinal evaluation revealed a significant reduction in the incidence of pleural violation for group 1 (3) versus group 2 (11) (p=0.014). This difference was not found to be surgeon specific. CONCLUSIONS: Sternotomy undertaken from the sternal notch proceeding downwards is shown to be associated with a reduced incidence of inadvertent pleural entry. Potential advantages for this approach also include reduced respiratory morbidity, less chest tube site complications and a trend to reduced length of hospitalization.     

Treatment of hemopneumothorax under thoracoscopic guidance: a case report

A 32-year-old man was admitted to our hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemithorax. Shock developed following drainage of 1,500 ml hemorrhagic pleural fluid. Following blood transfusion, emergency surgery was carried out. At operation under thoracoscopic guidance, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noted. The artery was successfully ligated with surgical clip, and the bulla was resected using EndoGIA. This case report indicates that hemopneumothorax can be safely operated on under thoracoscopic guidance after the patient has recovered from shock by adequate blood transfusion.     

The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department

OBJECTIVE: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. METHODS: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8-82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. RESULTS: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7. 1 days (range, 4-140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. CONCLUSIONS: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice.     

Renal stone fragments following shock wave lithotripsy

BACKGROUND: To reinforce the staple line of the emphysematous lung and thereby prevent air leakage during thoracoscopic operations, we have developed a procedure of lung excision that uses a gelatin-resorcinol-formaldehyde-glutaraldehyde (GRFG) glue-spread stapler. METHODS: Formaldehyde-glutaraldehyde (FG) jelly is prepared by mixing FG fluid with 2.5% sodium carboxymethyl cellulose. The FG jelly is placed in the stapler groove and staple holes, and a gelatin-resorcinol (GR) mixture is applied. The GRFG glue-spread stapler was applied to emphysematous lung cutting during thoracoscopic operations in 10 cases. RESULTS: An adhesion-strength test showed no difference in glue adhesion between FG fluid and FG jelly. An experiment using swine lung showed that with this newly developed stapler, no resistance in firing occurred, and GRFG glue covered every staple hole. Clinical application in 10 cases with emphysematous lung demonstrated no air leakage from the staple line, even long after the operation. CONCLUSIONS: Emphysematous lung excision using the GRFG glue-spread stapler during thoracoscopic operations is useful in preventing air leakage from the staple line and is a simple, safe, and low-cost procedure.     

Medical anthropology and infectious disease control

A 46-year-old woman complained four times of chest pains due to repeated right pneumothorax. This was improved by the right thoracic drainage each time. She was diagnosed as having catamenial pneumothorax from the fact that each episode of pneumothorax began with the first day of her menstrual cycle. She was admitted to our hospital in Jan. 1996 and operated on by the obliteration of pleuro-peritoneal fistulas on right diaphragm under video-assisted thoracoscopic surgery (VATS). No other abnormal lesions were found in the right pleural cavity and right lung. In this case, the pathophysiological mechanisms of pneumothorax might have been caused by the air influx from the peritoneal cavity to the right pleural cavity through the fistulas on the right diaphragm. VATS is minimally invasive surgery and very useful for the treatment of pleuro-peritoneal fistulas on the diaphragm. It should be emphasized that hormonal therapy is necessary after VATS of catamenial pneumothorax.     

Lung volume reduction surgery as an emergency and life-saving procedure

Lung volume reduction surgery (LVRS) is emerging as a promising and unique therapeutic option for rigorously selected patients with severe debilitating emphysema. A 51 yr old man with generalized emphysema developed bilateral pneumothoraces during his first holiday abroad. Due to respiratory insufficiency, intubation and mechanical ventilation were necessary. In total, six chest tubes were inserted but massive air leak persisted and his respiratory condition deteriorated due to bronchopneumonia and sepsis. The patient was transferred to Belgium. As a last resort, bilateral LVRS was performed through a median sternotomy. The most diseased areas of the upper lobes containing the air leak were resected bilaterally and a pleurectomy was associated. Three months after operation, there was a remarkable improvement in spirometric values with an increase in forced expiratory volume in one second of almost 100%. The results were sustained after a follow-up of 18 months. In this dramatic case, lung volume reduction surgery proved to be effective, and was even a life saving procedure.     

Global functioning of inpatients with obsessive-compulsive disorder, schizophrenia, and major depression

In April and May 1996, two cases of PDA ligation were performed firstly in Turkey by the method of video assisted thoracoscopic surgery (VATS) in Dokuz Eylül Medical Faculty, Thoracic and Cardiovascular Surgery Department. There was not any complication in these patients in the postoperative period and they were discharged on the second day in symptom-free condition by the detection of closed ductus in their echocardiographic examination. Between February 1993 and October 1996, a total of 46 patients have undergone interventional application by VATS. While in six of these patients the procedure could not be manipulated because of massive pleural fibrosis, there was no mortality or morbidity among the patients, and they were discharged on average on the second day. The ratio of complications, such as bleeding, air leak, arrhythmia and empyema are so low in these operations, and hospital stay, with return to work time are shorter than with the open technique.     

Pleural effusion: what next?

This article gives an overview of the aetiology, diagnostic evaluation and treatment of pleural effusions. A systematic approach including radiological and sonographic examinations and pleural fluid analysis is proposed with a view to selecting the most appropriate therapy. Common forms of exudative pleural effusions are explained in detail. For complicated parapneumonic effusions, new therapeutic options such as the use of fibrinolytics or thoracoscopic debridement are discussed. Talc slurry and thoracoscopic talc poudrage provide effective methods for pleurodesis in case of malignant effusions.     

Two cases of spontaneous hemopeumothorax

We experienced two cases of spontaneous hemopeumothorax. One case was a 17-year-old male with a complaint of back pain. A chest tube for rapid pleural evacuation disclosed hemorrhage as much as 3,000 ml, with drainage volume being gradually decreased. He needed about two month's admission because of complication of pyothorax. The other case was a 46-year-old male with a complaint of chest pain. Chest X-P gave the diagnosis of right hemopeumothorax. Thirty minutes later, he became shock, and five hours later, we performed an emergency intervention of video-assisted thoracoscopic surgery (VATS). Bleeding site of a funicular structure from the parietal pleura was stopped by clipping, with excellent postoperative results. Spontaneous hemopeumothorax is often indicated for early surgical intervention because of association with a high risk of hemorrhagic shock. In such a case, VATS is very helpful.     

Thoracoscopic bilateral lung volume reduction for diffuse pulmonary emphysema

OBJECTIVE: In a prospective study, we investigated the functional results, complications and survival of bilateral video-assisted thoracoscopic (VAT) lung volume reduction (LVR) in a selected group of patients with severe, nonbullous pulmonary emphysema. From January 1994 to September 1996, 42 of 143 candidates (13 female, 29 male, 42-78 years) were operated. They were short of breath on minimal exertion due to severe airflow obstruction and hyperinflation (FEV1 < 30%) pred., TLC > 130% pred., RV > 200% pred.). METHODS: LVR was performed bilaterally by VAT using endoscopic staplers without buttressing the staple lines. Pulmonary function test (PFT), MRC dyspnea score and 12 min walking distance were assessed preoperatively, at 3, 6 and 12 months. In addition lung function was measured at hospital discharge. RESULTS: The patients reported a marked relief of dyspnea, which persisted at all follow-up visits (P<0.001). FEV1 increased from 0.80 +/- 0.24 (L) to 1.14 +/- 0.41 (L) postoperatively, a 43% gain (P < 0.001). A relevant increase of FEV1 persisted for at least 1 year. The residual volume to total lung capacity ratio decreased from 0.64 to 0.56 at hospital discharge. The mean 12 min walking distance increased from 500 +/- 195 (m) to 770 +/- 222 (m) after 1 year (P < 0.001). The mean hospital stay was 13 +/- 5.5 days (median 12.0), drainage time was 9 +/- 4.3 (median 8.0) days. There was no 30 day mortality. Three patients died between 2 and 15 months postoperatively by non surgery related reasons. One patient underwent lung transplantation 5 months after surgical lung volume reduction. CONCLUSIONS: In a selected group of patients with severe, nonbullous pulmonary emphysema, bilateral LVR by VAT results in instantaneous postoperative improvement in pulmonary function and dyspnea. These favorable effects, including an amelioriation in exercise performance, lasted for at least 1 year.     

Using ARROWSMITH: a computer-assisted approach to formulating and assessing scientific hypotheses

The usefulness of Xe-133 and Tc-99m-MAA single photon emission computed tomography (SPECT) in identifying areas to be resected during video-assisted thoracoscopic lung reduction surgery for emphysema was examined. Twenty-nine patients with advanced emphysema were examined using Xe-133 and Tc-99m-MAA SPECT prior to and following surgery. For the Xe-133 dynamic SPECT, patients inhaled Xe-133 gas for 6 minutes. Equilibrium and subsequent washout SPECT images were acquired every 30 seconds for 6 to 7 minutes during spontaneous breathing. Ventilation was quantified by Xe-133 clearance time (T1/2) in addition to visual assessment. The patients underwent unilateral thoracoscopic volume reduction in the regions with abnormal Xe-133 retention and Tc-99m-MAA defect. All patients demonstrated marked, heterogeneous Xe-133 retention and Tc-99m-MAA defects preoperatively. The worst functioning areas were identified as nonventilated and noflow areas, or areas with air trapping and low perfusion. These changes were found even in patients with diffuse and symmetrical impairments on chest CT. After surgery, most of these "target areas" disappeared and pulmonary function tests demonstrated significant improvement. T1/2 correlated closely with the percent predicted FEV1 (%FEV) and 6-minute walk distance before and after surgery (p<0.0001). Xe-133 and Tc-99m-MAA SPECT imaging was useful in identifying "target areas" in the emphysematous lung. Directed unilateral thoracoscopic volume reduction based on these SPECT images is an effective treatment for emphysema.     

Three resected cases of pulmonary cryptococcosis

Case 1 was a 53-year-old female who had a small nodule in the right S3 segment on chest CT. As she was not diagnosed by transbronchial lung biopsy (TBLB), open thoracotomy was performed. Case 2 was a 65-year-old female who had a nodule with pleural indentation in the right S6 segment. As this nodule showed difficulty to differentiate from small lung carcinoma, thoracoscopic surgery was performed. Case 3 was a 63-year-old female who had multiple lesions with cavity in the left S4 and S5 segments, which was preoperatively diagnosed by TBLB. She was performed thoracoscopic partial resection of the lingular segment because of poor response to antimycotic agents. All cases received preventive antimycotic agents for one or two months after the operation. There was no recurrence or postoperative meningitis. Thoracoscopic surgery is the effective procedure for the diagnosis and treatment of the localized pulmonary cryptococcosis.     

Clipping of the thoracic duct with video-assisted thoracic surgery in the treatment of chylothorax after pulmonary resection

We describe a procedure for video-assisted thoracoscopic clipping of the thoracic duct to treat postoperative chylothorax. This technique was successfully performed on a 62-year-old man who developed chylothorax following right lower lobectomy and partial resection of the 11th and 12th vertebral bodies for squamous cell lung cancer. Because conservative therapy for 7 days failed to reduce the amount of pleural effusion, we performed thoracoscopic examination of the thoracic duct and found a site leaking chylous fluid. The thoracic duct was successfully and easily clipped resulting in complete elimination of the effusion in 2 days. Generally, chylothorax complicating pulmonary resection has been managed by medical treatment first, followed by surgical intervention in case that fail to respond to initial therapy. The newly designed video-assisted thoracic surgery procedure reduces the trauma, shortens the drainage period and hospital stay, and provides better exposure of the thoracic duct. We believe that this procedure can be carried out shortly after the occurrence of chylothorax.     

Appetite suppressant drugs as inhibitors of human cytochromes P450: in vitro inhibition of P450-2D6 by D- and L-fenfluramine, but not phentermine

BACKGROUND: We compared our results with bullous vs diffuse emphysema by performing a bilateral thoracoscopic stapled volume reduction technique in 15 patients (age 45-80, 10 males, five females). METHODS: Eight patients demonstrated bullous emphysema and seven patients diffuse emphysema. Lung reduction was performed with a bilateral thoracoscopic stapled technique utilizing bovine pericardium in the supine position. RESULTS: Comparison of the bullous versus diffuse groups revealed no significant differences in means for the following variables: length of air leak (7.5 vs 3.3 days); length of stay (8.1 vs 6.5 days); pre-op FEV1, (23% vs 22%); pre-op dyspnea index (3.4 vs 3.6). At 3 months the bullous subset had a highly significant improvement (p < 0.007) in FEV1 (88%) compared with the diffuse subset FEV1 (59%). CONCLUSIONS: These early results suggest that patients with bullous emphysema are at no greater risk and demonstrate a significantly greater improvement in FEV1 than patients with diffuse emphysema.     

The thoracoscope as diagnostic tool for solid mediastinal masses

BACKGROUND: Despite the accuracy of percutaneous biopsy of mediastinal masses under CT scan or sonographic control, there is still a need for surgical biopsy because of difficult location or because of insufficiency of the percutaneous biopsy, especially for those tumors requiring an immunological classification. METHODS: The thoracoscopic approach to mediastinal masses is an alternative to the usual surgical biopsies performed through thoracotomy, sternotomy, or anterior mediastinotomy. The procedure is performed under general anesthesia and one-lung ventilation. RESULTS: In a series of 47 cases, a histological diagnosis was obtained in 44 cases (93.6%). There was one hemorrhagic complication requiring thoracotomy (2.1%). The mean postoperative duration of stay was 3.2 days. CONCLUSIONS: Thoracoscopy is the method of choice in case of failure or contraindication of percutaneous biopsy. There is still a role for mediastinoscopy in treating paratracheal lymph nodes.     

Regurgitation through the morphologically pulmonary valve after additional aortopulmonary anastomosis

OBJECTIVE: Oesophagectomies have a high morbidity rate, mainly related to pulmonary complications. The aim of this work was to assess whether the thoracoscopic approach could reduce this morbidity. PATIENTS AND METHODS: We conducted a prospective study of the results of 26 attempts of esophagectomy using a right thoracoscopic approach. There were 17 males and 9 females having an average age of 47. The indication was a squamous cell carcinoma in 19 patients, an adenocarcinoma in 1 patient, a melanoma in 1 patient and a caustic stenosis in 5. The whole oesophagus was mobilized thoracoscopically, and the eosophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through and a cervical anastomosis. RESULTS: There were 5 failures for the following reasons: unresectable carcinoma (1 case), large tumour making a thoracoscopic dissection unsafe (1 case) and incomplete lung collapse making the exposure of the posterior mediastinum difficult (2 cases). The average time of the thoracoscopic procedure was 135 min. The post-operative course was uneventful in all but 5 patients who had a pulmonary complication: atelectasis (3 cases), right purulent pleural effusion (1 case), acute respiratory distress syndrome (1 case). The latter complication was lethal. Four out of 5 respiratory complications occurred in patients for whom the dissection was considered as difficult. Among the other complications, there were 5 anastomotic leakages and 3 laryngeal nerve palsy. The mortality rate was 3.8%. CONCLUSION: These initial results do not show a real benefit of the thoracoscopic approach for eosophageal dissection, especially for difficult oesophagectomies. Further evaluation of the technique is needed.     

Abdominal sonography for the diagnosis of bowel obstruction

Minimally invasive thoracoscopic staging for lung cancer was compared with re-staging by open thoracotomy in seventeen patients to evaluate whether videoimaged thoracoscopic staging was accurate. Seventeen patients underwent thoracoscopic staging initially with a closed videoimaged technique. These same patients then underwent an open thoracotomy and re-staging with a therapeutic resection for lung cancer. All patients underwent pleural evaluation and biopsy if indicated, thoracic hilar and mediastinal lymph node sampling, and then resection of the parenchymal lesion via a wedge resection, lobectomy or pneumonectomy. There was complete TMN stage correlation between the closed videoimaged thoracoscopic and open thoracotomy techniques. This preliminary study suggests minimally invasive videoimaged thoracoscopic staging is an accurate method to assess the stage of lung cancer to guide rational management.     

Is fetal neurologic and physical development accelerated in preeclampsia?

Tuberculosis remains a major health problem worldwide. The current role of video-assisted thoracoscopic surgery (VATS) in the management of this condition is unclear. We reviewed our experience over a 36-month period from a single institution. Thirty-seven patients (26 male, 11 female, with age ranging from 22 days to 71 years), in whom the final diagnosis was tuberculosis, underwent VATS procedures. There were 12 pleural biopsies, 3 decortications, 12 wedge lung resections, 5 drainages of empyema, and 5 lobectomies. All the patients were studied prospectively. There were no mortality or intraoperative complications. The overall median postoperative hospital stay was 4 days (range, 2 to 35 days). Postoperative parenteral narcotics requirement (mean, 310 mg meperidine hydrochloride [Pethidine]) was significantly less than a historic group of 30 patients who underwent conventional thoracotomy for lung resection or empyema drainage for tuberculosis (mean, 875 mg). Postoperative complications include 2 persistent air leaks over 7 days (5.4%) and 1 wound infection (2.7%). We conclude the following: (1) VATS is safe and effective in achieving the diagnosis of tuberculosis through pleural biopsies or wedge lung resection of indeterminate pulmonary nodules; it is particularly useful for those patients who are debilitated, thus making them poor candidates for conventional open surgery; (2) in patients with trapped lung or tuberculous empyema, VATS could achieve full lung reexpansion with minimal morbidity; and (3) therapeutic lung resection using VATS in patients with tuberculosis is technically demanding and potentially hazardous. Its role is, at present, limited.