Complications after video-assisted thoracic surgery

Video-assisted thoracic surgery (VATS) procedures have been adopted widely and rapidly for the treatment of a wide range of benign and malignant thoracic disorders. To date, there is only incomplete information available about the complications associated with these techniques. In this article, the available literature addressing the types and incidence of postoperative complications associated with VATS procedures is reviewed, as are the problems of incisional pain, alterations in respiratory function, and dissemination of malignancy following manipulation of tumors by VATS techniques.     

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 (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.     

Cost analysis for thoracoscopy: thoracoscopic wedge resection

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of video-assisted thoracic surgery in esophageal disease

Numerous applications of video-assisted thoracic surgery (VATS) in the management of diseases of the esophagus for structural, functional, benign, and malignant conditions have been reported. Indications and techniques for the use of VATS in the assessment and treatment of esophageal disease are discussed in this article. The need for careful evaluation of the safety, efficacy, and cost-effectiveness of these techniques is emphasized.     

Effect of minimally invasive thoracic surgical approaches on acute and chronic postoperative pain

Acute postthoracotomy pain and chronic postthoracotomy pain are significant problems leading to increased length of hospital stay and medical costs, reduction in patient quality of life and patient productivity, and potential immunologic derangement that may compromise oncologic surgical results. Minimally invasive surgical approaches can potentially benefit the patient by reducing postoperative pain-related morbidity. Objective data supporting our inclination that these VATS approaches are superior to open thoracic surgical techniques is accumulating. Further study of the relative costs, risks, and benefits of standard postoperative analgesic management (e.g., epidural analgesia) combined with limited thoracotomy compared to VATS techniques is warranted as we try to define the most effective perioperative management of the patient requiring pulmonary resection.     

New technology in diagnosis and treatment of diseases of the pleural space

Recent developments in video camera technology, new instruments, and advanced surgical techniques have increased the importance of video-assisted thoracoscopic surgery (VATS). Currently, VATS offers a new approach in the diagnosis and treatment of many thoracic conditions previously treated only by standard thoracotomy. In our experience, VATS is a safe, reliable, and effective alternative to thoracic surgery. With further improvements and refinements in video imaging and endoscopic instruments, more procedures will be technically feasible. The long-term results of VATS compared to open thoracotomy will require extensive follow up and prospective trials to determine its true value.     

Limited axillary thoracotomy vs video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been reported to have a higher pneumothorax recurrence rate than limited axillary thoracotomy (LAT). We investigated the cause of pneumothorax recurrence after VATS by comparing surgical results for VATS and LAT. METHODS: Ninety-five patients with spontaneous pneumothorax underwent resection of pulmonary bullae by VATS (n = 51) or LAT (n = 44). Operating duration, bleeding during surgery, number of resected bullae, duration of postoperative chest tube drainage, postoperative hospital stay, postoperative complication, and pneumothorax recurrence were analyzed to compare VATS and LAT in a retrospective study. RESULTS: The duration of surgery, postoperative chest tube drainage, and postoperative hospital stay was significantly shorter in VATS than in LAT cases (p < 0.0005 and p < 0.005). Bleeding during surgery was significantly less in VATS than in LAT cases (p < 0.005). Numbers of resected bullae were significantly lower in VATS (2.7 +/- 2.1) than in LAT cases (3.9 +/- 2.7) (p < 0.05). Postoperative pneumothorax recurrence was more frequent in VATS (13.7%) than in LAT cases (6.8%), but there was no significant difference. CONCLUSIONS: VATS has many advantages over LAT in treating spontaneous pneumothorax, although the pneumothorax recurrence rate in VATS cases was double that in LAT cases. The lower number of resected bullae in VATS than in LAT cases suggests that overlooking bullae in operation could be responsible for the high recurrence rate in VATS cases. We recommend additional pleurodesis in VATS for spontaneous pneumothorax to prevent postoperative pneumothorax recurrence.     

The current status of video-assisted thoracic surgery lobectomy

Video-assisted thoracic surgery (VATS) lobectomy appears to be a safe procedure that may have advantages over lobectomy by thoracotomy for selected patients. The published series of VATS lobectomies for lung cancer suggest that lobectomy by VATS offers survival comparable to that of lobectomy by thoracotomy. VATS lobectomy is associated with a low morbidity and mortality and, perhaps, a shorter length of stay than thoracotomy. VATS lobectomy is a reasonable treatment option for selected patients with Stage I lung cancer when it is performed by surgeons with the skills to perform a complete cancer operation via VATS.     

Video-assisted thoracoscopic closure of the delayed bronchial rupture after thoracoscopic resection of mediastinal bronchogenic cyst

Video-assisted thoracoscopic surgery (VATS) is an effective and less invasive modality for management of mediastinal disorders, but various complications can result from the procedure. This report describes a case of delayed rupture of the bronchus intermedius which occurred on postoperative day 1 after the patient underwent complete thoracoscopic removal of a mediastinal bronchogenic cyst (BC) with pericystic adhesions to the bronchus. The bronchial rupture was successfully treated by conventional surgical instruments through limited thoracotomy with video-assisted thoracoscopic guidance. In recognition of this possibility, VATS for a BC with adhesions should be carefully performed. Additionally, the role of VATS in bronchial repair is beneficial.     

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.     

Orbital tumors in children. Transcranial surgical approach

From March 1980 to December 1995, at the Department of Neurosurgery of the Instituto Nacional de Pediatría (INP), 23 patients were treated for orbital tumors. In this communication, the authors report on the clinical presentation, age, radiological findings, visual-evoked potentials, type of surgery, histological diagnosis, and results. Two kinds of surgical techniques were employed: craniotomy with orbital roof removal (NAFZIGER) and fronto-orbitotomy. Eleven patients had optic nerve gliomas, 3 had fibrous osseous dysplasia, 2 meningiomas, neurofibromas, Langerhans cells histiocytosis, and 1 case of Anaplastic astrocytoma, Teratoma, primitive Neuroectodermal tumor, germinoma with areas of choriocarcinoma. The results were evaluated for the quality of life in regard to the Karnofsky scale, tumor recurrence and postoperative visual-evoked potentials. It is important to note the very variable histological kinds of lesions found in this series that can be approached surgically with cranio orbitotomy with good results.     

Ross River virus in mosquitoes (Diptera:Culicidae) during the 1994 epidemic around Brisbane, Australia

BACKGROUND: Within a short period of time, video assisted thoracoscopic surgery (VATS) has revolutionised the practice of thoracic surgery. Most of the existing literature, however, is concentrated on the technical aspects. AIMS: We examined the impact of VATS on our practice and its implications. METHODS: We reviewed our thoracic case load two years before and two years after the introduction of VATS in our hospital. RESULTS: We have witnessed a rapid and progressive increase in our thoracic case load since the introduction of VATS. With increased experience, proportionally more cases were performed using VATS compared to conventional surgical access. The increased case load covered a wide range of thoracic diseases with the majority for spontaneous pneumothorax and pleural diseases. CONCLUSIONS: The higher case load is due to increased referrals which at least partly reflect earlier acceptance by both the patients and their physicians for surgical intervention. The changing indications for surgery and the high cost associated with VATS, however, could place extra demand on the healthcare, especially for some countries in Asia. Cost containment is therefore a high priority here. More research is greatly needed in this area.     

Accuracy of survey questions for geriatric urinary incontinence

BACKGROUND: Although the public perceives video-assisted thoracic surgery (VATS) as advantageous because it is less invasive than a thoracotomy, the medical community has questioned the safety of VATS lobectomy and its adequacy as a cancer operation. Reported series have not been able to address these issues because follow-up has been only short-term. METHODS: A multiinstitutional, retrospective review was performed in 298 consecutive patients who underwent VATS for a standard anatomic lobectomy with lymph node dissection for lung cancer. Pathologic staging was I in 233 (78%), II in 27 (9%), and IIIA in 38 (13%) patients. Kaplan Meier survival analysis was performed. RESULTS: The conversion rate from VATS lobectomy to thoracotomy was 6%, but none were for massive intraoperative bleeding. The only death (0.3%) was because of mesenteric venous thrombosis. Forty minor complications occurred in 38 patients (12.8%) undergoing VATS. The mean and median lengths of stay were 5+/-3.39 and 4 days, respectively. Recurrence in an incision occurred in 1 patient (0.3%). The Kaplan Meier 4-year survival for stage I was 70%+/-5%. CONCLUSION: The VATS lobectomy for bronchogenic carcinoma appears to be a safe operation, with the same survival as expected for a lobectomy done by thoracotomy.     

Muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia: an improved method for major lung resections

To decrease incisional pain, morbidity, and length of hospital stay (LOS) and, hopefully, to reduce costs, most surgical specialties have turned to minimally invasive procedures to access the body cavities during commonly performed operations. Video-assisted thoracic surgery (VATS) has emerged as the standard approach for a number of diagnostic and therapeutic procedures in thoracic surgery. Major lung resections (lobectomy, bilobectomy, and pneumonectomy), however, can be performed through an incision similar in size to the utility or access thoracotomy used in VATS to remove the specimen. The purpose of this study was to compare an oblique muscle-sparing minithoracotomy with intercostal nerve cryoanalgesia with the standard posterolateral thoracotomy incision and VATS to perform major lung resections. Forty consecutive patients with bronchogenic carcinoma, operated on by a single surgeon, were chronologically divided into two groups, each with equivalent age, sex distribution, physiologic parameters, tumor size, and clinical stage. In addition, data were collected from a MEDLINE search of all published studies in which major lung resections were performed via VATS. The first group (group A, n = 20) underwent posterolateral thoracotomy to access the chest cavity, whereas the patients in the second group (group B, n = 20) underwent oblique minithoracotomy with intercostal nerve cryoanalgesia. Group B compared favorably with group A in LOS (P = 0.002), narcotic requirements (P = 0.001), morbidity (P = 0.042), and cost (P = 0.058). Group B also compared favorably with VATS major lung resection published data regarding LOS and morbidity.     

Video assisted thoracoscopic thymectomy for myasthenia gravis

Thymectomy is now an established approach to the treatment of myasthenia gravis (MG). We used video assisted thoracoscopic surgery (VATS) in thymectomy. From June 1993 to May 1995, we performed VATS thymectomy for 10 cases (6 males, 4 females with age ranging from 9 to 76 years). Complete thymectomy was achieved in every case by examination of the thymic bed and resected specimen. There was no mortality and complications were few. Average hospital stay was 4.1 days. Compared with the conventional median sternotomy approach, VATS was associated with a shorter postoperative hospital stay and analgesic requirement. We believe that VATS thymectomy is technically feasible. However, its true role in the treatment of MG requires further study.     

Pleural drainage vs video-assisted minimally invasive surgery in the treatment of spontaneous pneumothorax. A retrospective study

The most frequent cause of spontaneous pneumothorax is bleb's disease of the lung. Considering that, pnx s. has a remarkable bent for relapsing, we think that it's necessary an aggressive treatment to resolve it. That's because pleural drainage is useful for a symptomatic resolution, VATS for an etiologycal one. To value the real efficacy of the treatment of VATS, we have effected a retrospective research between two classes of patients suffering from pnx s. admitted in our Institute from 1987 until 1991, one treated with pleural drainage (class A, 11 patients) and the other with VATS (class B, 13 patients). 1) Patients treated with pleural drainage were nearly double compared to class B. 2) In class A, the mean value of drainages were nearly double compared to class B. 3) Class A had a number of relapses 10 times more compared to B. 4) Considering the period of hospitalization, class A had a value nearly triple compared to B. 5) We've noticed that the mean value of the cost for episode of pnx s. in class A was more than 15% compared to class B and the cost for patient in class A was nearly double than in class B. We can affirm that, for the treatment of pnx s., the method of VATS rappresents a real success. We're passed from the "symptomatological treatment" of it to an aetiological one, joined to the prophylaxis of the relapse.     

Human immunodeficiency virus-1 infection among patients with sexually transmitted diseases in Bombay

Modern neuro-imaging caused a renewed interest in endoscopic techniques. Several indications for stereotactic endoscopy are illustrated. A prototype of a new four channel endoscope is used. Lesions in the posterior part of the third ventricle an even the fourth ventricle are reachable for biopsy. Cystic intra- or paraventricular lesions can be approached stereotactically and treated. Continuous rinsing is mandatory to preserve a clear vision.     

Thoracoscopic lung biopsy or open lung biopsy for interstitial lung disease

Both traditional open lung biopsy through a limited thoracotomy and VATS lung biopsy are effective methods for obtaining parenchymal samples in patients who have respiratory insufficiency and radiographic pulmonary infiltrates. For patients with slowly progressive disease processes, who require an elective biopsy, VATS biopsy is the procedure of choice because of the ability to visualize and sample multiple areas of the lung, and because of the decreased postoperative pain. On the other hand, when patients are critically ill and already on high-level ventilatory support, the VATS method offers no advantages over the standard minimal thoracotomy.     

Transaortic division of the mitral subvalvar apparatus

Adequate exposure of the mitral valve can be difficult to obtain through a median sternotomy. A variety of techniques have been described to facilitate exposure in this situation. This report describes the use of trans-aortic technique which allows easy and accurate division of the mitral subvalvar apparatus. The mitral valve can then be approached through a left atriotomy, everted and the excision completed.