Video-assisted thoracic surgery for lung volume reduction surgery

Lung volume reduction surgery by video thoracoscopy can result in significant improvement in quality of life and pulmonary function for selected patients suffering from severe emphysema. Clinical trials comparing the use of lasers versus staples, unilateral versus bilateral procedures, and video surgery versus mediansternotomy are summarized. Patient selection and patient care issues are addressed. Information gathered from the selection, evaluation, and study of almost 500 patients treated surgically for emphysema at a single institution is summarized.     

Video-assisted thoracic surgery thymectomy for myasthenia gravis

Video-assisted thoracic surgery thymectomy was employed in the management of myasthenia gravis in a series of 20 patients. As the technique evolved, the authors preferred a right-sided approach, and the technical details of the process are discussed. At a mean follow-up of 30 months, clinical results are comparable to published series of other approaches. It is hoped that the superior cosmesis associated with this less-invasive approach leads to earlier thymectomy in management of this disease.     

Video-assisted thoracic surgery for diagnosis of the solitary lung nodule

The finding of a solitary pulmonary nodule is a frequent clinical problem. This article outlines the current recommendation for diagnostic management. Video-assisted thoracic surgery (VATS) has emerged as an excellent diagnostic tool that can reduce the incidence of thoracotomy for benign nodules while allowing expeditious treatment of early malignancies. The surgical techniques of VATS are discussed.     

Video-assisted thoracic surgery in patients with spontaneous pneumothorax

Following the development of video-assisted technologies and the principle of minimally-invasive surgery thoracoscopy has finally established itself as an integral part of the surgeon's armamentarium in the treatment of spontaneous pneumothorax. This procedure was performed on 18 patients at the Department of Cardio-Thoracic Surgery of the Medical University in Vienna from October 1995 to April 1996 and on 5 patients at the Department of Thoraco-Abdominal Surgery of the Medical University in Plovdiv from October 1996 to January 1997, all of which had been diagnosed as having complicated spontaneous pneumothorax. The main indications were: recurrent spontaneous pneumothorax or persistent pneumothorax following a five-day unsuccessful drainage of the pleural cavity. All our patients underwent partial parietal pleurectomy down to the level of the third intercostal space. Apical blebs were found in 14 patients and atypical wedge resection was performed. The authors used three trocars 5-12 mm in diameter. The thoracoscope was inserted in the fifth intercostal space in the midaxillary line. The other two operative trocars were inserted in the anterior and posterior axillary lines, respectively. The mean postoperative stay was 6 days. Our results support the view that video-assisted thoracic surgery is technically feasible and safe, associated with decreased perioperative pain and opiate requirements, shorter hospital stay, excellent cosmetic results, low recurrence rate, early return to routine activity and minimal morbidity and is therefore superior to conventional thoracotomy.     

Video-assisted thoracoscopic surgery to the upper thoracic spine

BACKGROUND: The standard open technique for exposure of the upper thoracic spine, T1-T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically. METHODS: A new approach, the so-called "extended manipulating channel method," was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients' ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy. RESULTS: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients. CONCLUSIONS: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5-3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities.     

Video-assisted thoracic surgical resection with the neodymium:yttrium-aluminum-garnet laser

Since January 1991, we have performed 79 video-assisted neodymium: yttrium-aluminum-garnet laser resections for pulmonary nodular or interstitial disease. Pathologic examination demonstrated malignancy in 59 patients (32 primary and 27 metastatic), benign nodules in 11, interstitial processes in seven, and granulomatous disease in two. There were 39 men and 40 women with a mean age of 63.4 +/- 12.5 years. Thirty-nine patients underwent resection with the neodymium:yttrium-aluminum-garnet laser alone and 40 had lesions resected with a combination of laser and endoscopic stapling. Laser excision was performed for lesions deep in the substance of the lung or on its effaced surface; both are locations that make stapling alone difficult. Fifteen of 32 patients with a diagnosis of primary lung malignancy underwent open anatomic resections. Pulmonary reserves of the other 17 patients were inadequate for further resection. Operative time, duration of chest tube placement, length of hospital stay, and complication rate were compared with those for 72 patients undergoing video-assisted thoracic surgical resection of nodules with staplers alone. Although operative time for laser-assisted procedures was longer (p < 0.05), there were no differences in duration of chest tube placement or hospital stay compared with stapled resections. The complication rate for laser-treated cases was not higher than for stapled resections and consisted primarily of air leaks lasting 2 to 7 days. The neodymium:yttrium-aluminum-garnet laser is a safe and precise primary or adjunctive tool for video-assisted thoracic surgical pulmonary resection.     

Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience

Between September 1992 and October 1997, we performed 128 video-assisted thoracic surgery (VATS) lobectomies. The indications for surgery were 103 cases of lung cancer, 11 cases of bronchiectasis, 8 cases of granuloma, 4 cases of benign lesions, and 2 cases of metastatic tumors. Of the 103 cases of lung cancer, 62 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, and the 4-year survival rate of final stage I lung cancer was 94.4%. VATS lobectomy is far less invasive than open thoracotomy, and survival rates after VATS lobectomy with extended lymph node dissection are comparable with those after open thoracotomy. Thus, VATS lobectomy with extended lymph node dissection should be considered as a standard surgical alternative to open thoracotomy for stage I lung cancer.     

Video-assisted pulmonary resection surgery. Technique, indications and first results

Video-assisted thoracic surgery (VATS) is a compromise between conventional thoracic surgery performed via a thoracotomy of variable dimensions and surgical videothoracoscopy, which, using only small operating channels, requires the use of specific instruments, gives a field of vision exclusively by video camera and raises the delicate problem of extraction of the resection specimen. VATS is performed via a minithoracotomy, 3.5 to 5 cm long, using a video camera. In this way, the operator has two forms of vision throughout the operation: direct vision through the orifice of the minithoracotomy and visualization of the video screen. This technique also allows extraction of the resection specimen at the end of the operation. Between February and May 1993, 20 patients (14 males and 6 females with a mean age of 56 years) underwent lung resection by VATS (18 lobectomies and 2 pneumonectomies). Eighty-eight patients had a malignant tumour and 2 had a benign disease. Lymph node dissection was routinely performed in patients with a malignant lesion. The mean size of the tumours was 3.2 cm. The operative mortality was nil. The mean operating time was 154 minutes. The postoperative course was uneventful in 14 patients, but two cases of atelectasis on DO, one bronchial infection and one chylothorax, treated medically, were observed. The authors report the current criteria of their indications as the feasibility and reliability of this new technique. Results on pain and patient comfort, postoperative analgesia requirements, recovery of respiratory function and possible long-term sequelae remain to be demonstrated, which is the objective of a current prospective study.     

Video-assisted thoracoscopic surgery for pneumothorax

A 28-year-old Japanese woman who suffered from mononeuritis multiplex was admitted to our hospital. Serological study revealed cryoglobulinemia (type III), hypocomplementemia, high titers of rheumatoid factor (RF), and positive antihepatitis C virus (HCV) antibody. Nerve conduction velocities were slower in sensory nerves than in motor nerves. Biopsied sural nerve showed a marked decrease of myelinated fibers but no evidence of angitis. She received plasma exchange and cryoglobulinpheresis over a period of 2 months with approximately 2.0 L (40 ml/kg) of plasma replaced in each procedure. Both plasma exchange and cryoglobulinpheresis alleviated clinical symptoms, and nerve conduction velocities were improved in several nerves. The serum cryoglobulin level was markedly reduced after the treatment together with the recovery of the C4 level. Thus, complements appeared to be consumed in large quantities in the presence of cryoglobulinemia in this patient. Efficacy of cryoglobulinpheresis indicates the possibility that cryoglobulins produced in association with HCV infection played a role in damaging the nerve directly through the activation of the complement system.     

Video-assisted venous surgery

The use of intraoperative angioscopy, till now utilized exclusively in arterial surgery, is now used also in venous surgery. From January 1992 54 patients underwent to video-guided venous surgery: 23 cases of external valvuloplasty of the sapheno-femoral junction (EV-SFJ), 25 cases of hemodynamic correction of varicose veins (French acronyms CHIVA), 5 cases of high ligation plus long saphenous vein intraoperative sclerotherapy (HL-IS) 1 case of sub-fascial perforators interruption (SPI), the only extraluminal videoguided procedure. We have used 3 different video-angioscopes: a 1 mm monofibroscopy let in a 6 Fr Fogarty catheter, a disposable 2,8 mm colangioscope and a 2,2 mm operative angioscope. For the perforators interruption we have utilised the thoracoscope. EV-SFJ: the angioscopy has confirmed the presence of normal valvular cusps in a dilated vein wall in 21 cases, so excluding 2 patients from the planned treatment. At the end of the operation the angioscope has verified the reapproach of valvular cusps. CHIVA: the angioscopy has allowed to identify the exact points of the superficial venous system which should be interrupted, according to the Franceschi's theory. This procedure can avoid the technical errors due to intraoperatory misleadings of the duplex mapping. HL-IS: consists of a classic high ligation followed by long saphenous vein intraoperative sclerotherapy. The angioscopy has allowed a complete deconnection of the long saphenous vein from tributaries and perforators. Furthermore has facilitate the proportional distribution of the sclerosing agent along the long saphenous vein. SPI: the videoassistance have permitted the identification of the insufficient perforating veins reducing their surgical exposures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Combined surgery for coronary artery disease and thoracic aortic disease

Combined surgery in 6 cases who had coronary artery disease and thoracic aortic disease simultaneously was analyzed. Case # 1 had ascending aortic replacement under deep hypothermic circulatory arrest because of iatrogenic aortic dissection caused by aortic clamp during the routine coronary artery bypass grafting (CABG). Case # 2 had DeBakey type II chronic dissection. Case # 3 had type I aortic dissection 4 years after the initial CABG. Both case # 2 and # 3 had ascending aortic replacement under retrograde cerebral perfusion along with CABG. Transverse aortic replacement was performed in case # 4, # 5 and # 6 under selective cerebral perfusion along with CABG. Case # 4 was associated with ascending-transverse aortic aneurysm. Case # 5 had aortitis syndrome complicated with severe coronary ostial stenosis and cervical branch stenosis. Case # 6 also had aortitis syndrome, severe coronary ostial stenosis, heavily calcified ascending-transverse aorta, and mitral and aortic regurgitation. This case had mitral and aortic valve replacement additionally. Case # 2 died of low cardiac output syndrome and multi-organ failure postoperatively. Case # 4 did not recover from profound shock that followed the preoperative acute myocardial infarction. The problems of low cardiac output syndrome caused by long interval of ischemic cardiac arrest, and also the problems of proximal anastomotic site of saphenous vein grafts were discussed.     

Video-assisted thoracoscopic surgery for spontaneous hemopneumothorax

PURPOSE: This study examined the usefulness of magnetic resonance imaging (MRI) in assessing whether parotid tumors were located in the superficial or deep lobe. PATIENTS AND METHODS: Eight patients with parotid gland tumors underwent MRI using a spin echo pulse sequence. T1- and T2-weighted images were obtained. To assess tumor localization in the parotid gland, two anatomic landmarks were used: 1) a line connecting the lateral surface of posterior belly of digastric muscle and lateral surface of the cortical bone of ascending ramus (facial nerve [FN] line) and 2) the relationship to the retromandibular vein (RV). Results of all MRI examinations were compared with the surgical findings. RESULTS: Seven of eight cases were correctly diagnosed using the FN line criterion. Five of eight cases were correctly diagnosed using the RV criterion. CONCLUSION: MRI is an excellent modality to show tumor localization in the parotid gland.     

Video-assisted thoracoscopy for pleural disease

Thoracoscopy has been a valuable modality for the diagnosis and treatment of pleural-based disease for almost 100 years. With the development of video technology and improved instrumentation, video-assisted thoracoscopy is the procedure of choice for effusions of unknown origin, pleural mass biopsy, and free-flowing empyema drainage when conventional techniques fail. Reported success rates have been very good for diagnosis and treatment of both benign and malignant disease, and the morbidity is low.     

Video-assisted thoracic surgery--lobectomy, pneumonectomy]

Pneumonectomy performed by the V.A.T.S. method-Video Assisted Thoracic Surgery-calls for great skill, concentration and experience of the surgeon and puts greater demands on him than classical surgery. Minithoracotomy (5-10 cm) combined with videothoracoscopy have the joint advantages of miniinvasive operation and safety and radicality of the operation. During surgery lymphadeaectomy can be performed, it is possible to suture injured arteries or veins. Postoperative recovery is markedly better after V.A.T.S. than after conventional surgery. In the group of the first 11 V.A.T.S. lobectomies and one V.A.T.S. pneumonectomy the authors recorded a very low morbidity and zero mortality. The patients usually do not suffer from postoperative pain and rehabilitate well. The easier, less painful postoperative course is associated with earlier discharge, rapid convalescence and early return to work. V.A.T.S. is, no doubt, a benefit for the patient with regard to the postoperative response and course of recovery.     

Video-assisted thoracic surgical procedures: the Mayo experience

In neurodegenerative disorders, hyperphosphorylated tau proteins aggregate into abnormal filaments. In the present study, tau protein alterations were studied in one corticobasal degeneration and seven Pick's disease cases using specific immunological probes. The typical lesions of corticobasal degeneration and Pick's disease were revealed by immunohistochemistry, including the presence of Pick bodies and achromatic swollen neurons, neuritic alterations, and neurofibrillary tangles. Tau-immunoreactive glial tangles were also observed. By immunoblotting, the case of corticobasal degeneration was characterized by the tau profile previously reported to occur in progressive supranuclear palsy with an intense labeling of the two tau 64 and 69 bands, while tau 55 was not visualized. In Pick's disease cases with Pick bodies and neurofibrillary tangles, a tau triplet similar to that encountered in Alzheimer's disease (tau 55, 64 and 69) was detected. Furthermore, a particular tau profile was found in four Pick's disease cases showing only Pick bodies and no neurofibrillary tangles. In these cases, tau 55 and 64 were strongly immunoreactive, whereas tau 69 was almost unlabeled. These differences are likely to be related to particular pools of tau isoforms present within the degenerating neurons. Since there is a great diversity of neurodegenerative disorders with substantial clinical and neuropathological overlap, the electrophoretic profile of tau proteins could represent a useful marker for the type of neurodegeneration.     

Video-assisted thoracoscopy in the evaluation of penetrating thoracic trauma

We report an unusual case of bilateral chronic conjunctivitis and corneal scarring in a boy with X-linked hypogammaglobulinaemia (XLH) who did not respond to the usual antibacterial and antiviral therapy. An immunofluorescence test for Chlamydia trachomatis from an eye swab was strongly positive. Within days of commencement of local and systemic tetracycline therapy, he showed marked improvement. Since conjunctival follicle formation, which depends on the presence of a B-cell population, may not occur in XLH, clinical examination in chlamydia conjunctivitis may be misleading and lead to a delay in diagnosis and treatment with resulting corneal complications, unless laboratory evidence of chlamydia infection is specifically sought.     

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.     

Video-assisted thoracoscopy in the evaluation of penetrating thoracic trauma

We report a case of cardiovascular collapse and death occurring intraoperatively during the prophylactic nailing of a metastatic femur using an unreamed femoral nail. The cause of death, as documented by the autopsy, was a massive fat embolism. The risk of fat embolism while performing intramedullary nailing is well known and has been linked to the process of medullary reaming. Unreamed femoral interlocking nails recently have become available. Although recent reports in the literature have concluded that the risk of fat embolism appears less likely while using unreamed implants, the surgeon should carefully consider the indications for any type of intramedullary fixation, particularly when dealing with unbroken femurs exhibiting impending pathologic fracture, or when preexisting pulmonary disease such as metastasis is present.