Combined Thoracoscopy Research Articles

Efficacy of two-lung ventilation with different tidal volume assisted by CO 2 pneumothorax for airway management in patients undergoing radical resection of esophageal cancer using combined laparoscopic and thoracoscopic approach

Objective: To evaluate the efficacy of two-lung ventilation with different tidal volume assisted by CO2 pneumothorax for airway management in patients undergoing radical esophagectomy using combined thoracoscopic and laparoscopic approach. Methods: One hundred and eighty patients undergoing radical esophagectomy using combined thoracoscopy and laparoscopy under general anesthesia from the Affiliated Cancer Hospital of Zhengzhou University between February and September 2019 were randomly divided into three groups (group V1, V2, V3, n=60) according to the tidal volume (TV) used. The TVs of group V1-V3 were 4, 5, 7 ml/kg during thoracoscopic surgery, respectively. All the patients were intubated with a single-lumen endotracheal tube and underwent two-lung ventilation assisted by continuous positive pressure CO2 pneumothorax in group V1, V2 and V3, with the CO2 pressure of 10 mmHg (1 mmHg=0.133 kPa) and the frequency of 20 times/min. Mean arterial pressure (MAP) and heart rate (HR) were recorded before thoracoscopic surgery (T1), 30 minutes after thoracoscopic surgery (T2), at the end of thoracoscopic surgery (T3), after thoracoscopic surgery and 30 minutes after two-lung intermittent positive pressure ventilation, respectively. The results of arterial blood gas were collected at T1, T2, T3 and T4. Recovery time from anesthesia, consciousness recovery time, and lung collapse condition were recorded. Results: At T2, the value of MAP in group V1 was (81±10) mmHg, which was higher than those of group V2 [(69±7) mmHg] and group V3 [(71±8) mmHg], with a statistically significant difference (F=9.270, P<0.05). Meanwhile, at T2, the value of HR in group V1 was (83±7) times/min, which was higher than those of group V2 [(68±6) times/min] and group V3 [(71±7) times/min], and there was a statistically significant difference (F=23.460, P<0.05). However, at T2, the values of arterial partial pressure of oxygen (PaO2) in three groups were (262±16), (249±16) and (241±20) mmHg, respectively, with no statistically significant difference (F=1.929, P>0.05). At T3, the value of arterial partial pressure of carbon dioxide (PaCO2) in group V3 was (46±5) mmHg, which was lower than those of group V1 [(63±9) mmHg] and V2 [(62±10) mmHg], with a statistically significant difference (F=20.890, P<0.05). Moreover, at T3, the value of pH in group V3 was (7.35±0.04), which was higher than those of group V1 (7.28±0.04) and V2 (7.32±0.04), and there was a statistically significant difference (F=9.309, P<0.05). Additionally, the satisfaction rates of lung collapse in group V3 was 57.1%, which was lower than those of group V1 (94.7%) and group V2 (96.3%), with a statistically significant difference (χ²=7.601, P<0.05). There was no statistical significance in the time of awakening and consciousness recovery among three groups (F=1.020 and 1.110, both P>0.05). Conclusion: The two-lung ventilation with 5 ml/kg tidal volume assisted by CO2 pneumothorax has advantages in terms of hemodynamics and surgical field exposure, and is more suitable as the appropriate dose for respiratory management in patients undergoing radical resection of esophageal cancer using combined thoracoscopic and laparoscopic approach.

687 ADVERSE EVENTS DURING MINIMALLY INVASIVE ESOPHAGECTOMY IN PRONE POSITION

Abstract Since the initial description of laparoscopic fundoplication in 1991 for the treatment of gastroesophageal reflux disease, different minimally invasive procedures have been developed until nowadays, when esophagectomy is performed using combined thoracoscopy and laparoscopy. Objective: The aim of our study is to analyze the intraoperative complications of minimally invasive esophagectomy in prone position. Methods Between November 2011 and January 2021, 70 patients underwent minimally invasive esophagectomy in prone position in the Hospital Interzonal General de Agudos General San Martín and private practice of La Plata city. Results During the abdominal stage one patient presented coronary vessel injury and the other with short vessel injury. The complications occurring in the thoracic stage included lung injury, azygos arch injury, thoracic duct section, laryngeal recurrent nerve lesion, main stem bronchus injury, and pericardium lesion, during lymph node resection. Most of these complications occurred in the first 30 patients, while in the remaining 40 cases only two complications (p value = 0.4). Conclusion Minimally invasive esophagectomy in prone position is a feasible and safe procedure that can cause serious intraoperative complications due to its complexity. Although the results of our series did not show statistically significant differences, the number of complications during surgeries performed by the same team showed an important reduction associated with better training.

Adverse events during minimally invasive esophagectomy in prone position associated with the learning curve

Background: Since the initial description of laparoscopic fundoplication in 1991 for the treatment of gastroesophageal reflux disease, different minimally invasive procedures have been developed until nowadays, when esophagectomy is performed using combined thoracoscopy and laparoscopy. Objective: The aim of our study is to analyze the adverse events of minimally invasive esophagectomy in prone position during the learning curve. Material and methods: Between November 2011 and June 2017, 36 patients underwent minimally invasive esophagectomy in prone position in the Hospital Interzonal General de Agudos (HIGA) San Martín and the Instituto de Diagnóstico de La Plata. Results: During the abdominal stage one patient presented coronary vessel injury. The complications occurring in the thoracic stage included lung injury (n =2), azygos arch injury (n = 1), thoracic duct dissection (n = 1), laryngeal recurrent nerve lesion (n = 1) and main stem bronchus injury (n = 1) during lymph node resection. Most of these complications occurred in the first 20 patients, while in the remaining 16 cases only lung injury occurred (p = 0.10) Conclusion: Minimally invasive esophagectomy in prone position is a feasible and safe procedure that can cause serious intraoperative complications due to its complexity. Although the results of our series did not show statistically significant differences, the number of adverse events during surgeries performed by the same team showed an important reduction associated with better training.

A novel hybrid approach for enucleation of esophageal leiomyoma.

Esophageal leiomyoma is the most common benign tumor of the esophagus, which usually arises from the muscularis propria or muscularis mucosae. Incidence of benign esophageal neoplasms was reported to be in the range of 0.005% to 7.9% in autopsy cases, while leiomyomas account for 70–80% of them (1). Options for management include surveillance for small-sized tumors and surgical or endoscopic resection for large or symptomatic ones. Leiomyoma is commonly located in the lower two-thirds of the esophagus. In open surgery, right-sided surgical approach is preferred for lesions in the middle and upper esophagus, and left-sided approach for those in the distal lower esophagus. Video-assisted thoracoscopic surgery (VATS) for esophageal leiomyoma was first described by Everitt in 1992 (2,3). As scattered researches reported, enucleation of benign esophageal tumors can be performed effectively and safely with low morbidity (4-6), mostly through right-sided approach. The major complication after the enucleation of esophageal leiomyomas is mucosal injury, which may lead to esophageal leakage or perforation. We hereby report a novel approach using combined thoracoscopy and endoscopy to facilitate tumor removal and prevent mucosal injury.

A novel hybrid approach for enucleation of esophageal leiomyoma

Esophageal leiomyoma is the most common benign tumor of the esophagus, which usually arises from the muscularis propria or muscularis mucosae. Incidence of benign esophageal neoplasms was reported to be in the range of 0.005% to 7.9% in autopsy cases, while leiomyomas account for 70–80% of them (1). Options for management include surveillance for small-sized tumors and surgical or endoscopic resection for large or symptomatic ones. Leiomyoma is commonly located in the lower two-thirds of the esophagus. In open surgery, right-sided surgical approach is preferred for lesions in the middle and upper esophagus, and left-sided approach for those in the distal lower esophagus. Video-assisted thoracoscopic surgery (VATS) for esophageal leiomyoma was first described by Everitt in 1992 (2,3). As scattered researches reported, enucleation of benign esophageal tumors can be performed effectively and safely with low morbidity (4-6), mostly through right-sided approach. The major complication after the enucleation of esophageal leiomyomas is mucosal injury, which may lead to esophageal leakage or perforation. We hereby report a novel approach using combined thoracoscopy and endoscopy to facilitate tumor removal and prevent mucosal injury.

Improved early diagnosis of difficult cases of tuberculous pleural effusion by combination of thoracoscopy with immunological tests

IntroductionAlthough pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. The aim of this study was to evaluate the performance of commonly used laboratory tests for the early diagnosis of difficult cases of pleural effusion. MethodsPatients with undiagnosed pleural effusion were enrolled and subjected to five laboratory tests including thoracoscopy, pleural fluid adenosine deaminase assay (ADA), serum tuberculosis antibody test (TB-antibody), tuberculin skin test (TST), and T-SPOT.TB assay. The diagnosis of TP was established based on pleural histology and mycobacterial culture. The different tests were compared for diagnostic performance. ResultsA total of 106 patients were enrolled; their mean age was 53 years and 70.8% were male. Seventy-two (68%) of them were confirmed to have TP. When used individually, the five laboratory tests showed highly variable performance parameters, including sensitivity ranging from 46% to 92% and specificity ranging from 33% to 82%. When used in different combinations, thoracoscopy combined with TST or TB-antibody showed the optimal performance parameters, with a sensitivity of 80.8% and a specificity of 85.7%. ConclusionsThe results of this study suggest that the combination of thoracoscopy with TST or TB-antibody test is the best choice for the early diagnosis of difficult cases of TP in high TB burden countries.

Two cases of combined thoracoscopy and open chest surgery for locally advanced lung carcinoma

Thoracoscopic surgery is becoming more widely used in thoracic surgery and has an increasingly important role to play. However, its use for locally advanced carcinoma (clinical stage T3-4) remains controversial. We adapted our procedure by combining thoracoscopy and open chest surgery (combination surgery) with the aim of reducing invasiveness while ensuring that the operation is safe and curative. Here we describe our experience. Case 1 was a man in his 60s who underwent induction chemoradiotherapy (cisplatin plus vinorelbine plus 40 Gy radiotherapy) followed by radical surgery for a left apical lung carcinoma with chest wall invasion. Case 2 was a woman in her 70s who repeatedly had pneumonia and who underwent radical surgery for left apical adenocarcinoma that was expected to have strong adhesions to the thoracic wall. A thoracotomy incision may be required in cases of stage T3-4 lung cancer to access the hilar region and dissect the resected tumor and surrounding organs. In such cases, adding thoracoscopy to either one of these procedures may enable the use of a smaller incision in the chest wall. In both cases, complete resection with no residual tumor or complications was achieved, with the patients being discharged 3-8 days postoperatively. Cases 1 and 2 both remain recurrence free after 1.5 and 3 years, respectively). This suggests that having a thorough understanding of the features of both thoracoscopic and open chest surgery and integrating the two may enable surgery to be safely and less invasively performed while ensuring a curative effect.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Efficacy analysis of Da Vinci robot-assisted esophagectmy and combined thoracoscopy- and laparoscopy-assisted esophagectomy

Objective To compare the clinical efficacy of Da Vinci robot-assisted esophagectomy and combined thoracoscopy- and laparoscopy-assisted esophagectomy for esophageal cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 116 patients who underwent minimally invasive radical resection of esophageal cancer in the Shanghai Chest Hospital of Shanghai Jiaotong University between November 2015 and September 2016 were collected. Fifty-eight patients undergoing combined thoracoscopy- and laparoscopy-assisted esophagectomy and 58 undergoing Da Vinci robot-assisted esophagectomy were respectively allocated into the thoracoscopy- and laparoscopy-assisted and Da Vinci robot-assisted groups. Patients received esophagectomy by right thorax-left cervico-abdominal triple incisions, thorax-cervico 2-field lymph node dissection of esophageal cancer and digestive tract reconstruction via assisted incision. Observation indicators: (1) surgical and postoperative situations; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect the survival of patients and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were described as ±s. Measurement data with skewed distribution were described as M (range). Comparison between groups was analyzed by the nonparametric test, and comparisons of count data were done by the chi-square test and Fisher′s exact probability. Results (1) Surgical and postoperative situations: all patients received successful surgery, without conversion to open surgery. The number of lymph nodes dissected along the recurrent laryngeal nerve (RLN) and duration of postoperative hospital stay were 2.8±2.2, 13 days (range, 9-131 days) in the thoracoscopy- and laparoscopy-assisted group and 4.8±3.7, 11 days (range, 7-81 days) in the Da Vinci robot-assisted group, respectively, with statistically significant differences between the 2 groups (t=3.480, Z=2.361, P 0.05). Some of the patients had postoperative multiple complications. Patients with anastomotic leakage received local dressing changes, continuous gastrointestinal decompression and vacuum aspiration. The pronunciation and bucking response were observed in patients with injury of the RLN (unilateral injury). Patients with pleural effusion received pleural puncture fluid or closed thoracic drainage. Patients with pulmonary infection underwent antibiotic therapy and regular aerosol inhalation. Patients with respiratory failure underwent tracheotomy and assisted breathing with ventilator. Patients with chylothorax received fasting and closed thoracic drainage. Patients with arrhythmia were treated by drug. Patients with tracheo-esophageal fistula underwent conservative treatment. All the patients with complications were improved or cured. There were no wound infection, deep venous thrombosis of lower extremity, pulmonary embolism, reoperation and death within 30 days postoperatively in patients of 2 groups. (2) Follow-up and survival situations: all the 116 patients were followed up for 5-15 months, with a median time of 8 months. Numbers of patients with tumor-free survival, tumor recurrence and tumor metastasis were 50, 6, 4 (2 with simultaneous tumor recurrence and metastasis) in the thoracoscopy- and laparoscopy-assisted group and 51, 5, 4 (2 with simultaneous tumor recurrence and metastasis) in the Da Vinci robot-assisted group, respectively, showing no significant difference between the 2 groups (χ2=0.077, 1.000, P>0.05). Conclusions Da Vinci robot-assisted esophagectomy is safe and feasible in the treatment of esophageal cancer. Compared with combined thoracoscopy- and laparoscopy-assisted esophagectomy, Da Vinci robot-assisted esophagectomy has comparable operation time, and is associated with a greater yield of lymph nodes along the RLN. Key words: Esophageal neoplasms, squamous cell carcinoma; Radical section; Da Vinci robotic surgical system; Thoracoscopy; Laparoscopy

A simplified protocol of combined thoracoscopy and laparoscopic excision for large subdiaphragmatic hepatic hydatid cysts

Human hydatid disease caused by echinococcus granulosus is one of the commonest zoonosis and it primarily affects the liver. Amongst, the various treatment options, surgical management with removal of its contents and pericystectomy under the cover of anti-helminthic is the treatment of choice. Large hydatid cysts located in the posterosuperior aspect of liver often require thoracic approach. In this context, we describe an innovative combined thoraco-laparoscopic technique for the surgical treatment of large subdiaphragmatic hepatic hydatid cyst.

Medical thoracoscopy and gastroscopy for the treatment of intrathoracic anastomotic leakage following esophagectomy

Intrathoracic anastomotic leakage following esophagectomy is extremely difficult to manage appropriately. The outcomes of conservative management strategies are often disappointing, particularly in patients who develop adhesions of the pleural cavity and multiloculated empyema. This study describes a novel approach using combined thoracoscopy and gastroscopy in two cases. Thoracoscopy under local anesthesia was used to dissect the septations within the multiloculated empyema and remove the infected focus by direct visualization, and gastroscopy was subsequently performed to place a nasogastric or sump tube around the leak. The outcomes of both procedures were satisfactory: the empyemas almost completely resolved, the anastomotic leak closed quickly and there was adequate lung re-expansion. Accordingly, the combination of thoracoscopy and gastroscopy for the treatment of intrathoracic anastomotic leak post-esophagectomy may be an effective, safe, minimally-invasive, simple and inexpensive procedure.

Thoracoscopic and laparoscopic repair of complicated Bochdalek hernia in adult

Bochdalek's hernia is a congenital defect of the diaphragm that occurs predominantly in children. Perforation or necrosis of the involved organ is a feared complication and surgical repair constitutes the gold standard of treatment. We present a case of a 42-year-old female patient who presented with a 3-month history of left-upper-quadrant abdominal pain, nausea, tachycardia, and early postprandial vomit. Physical exploration was remarkable for audible peristalsis in the left hemithorax. Total white blood count was elevated and chest X-rays showed images of intestines in the left hemithorax. Tomography with double contrast reported left colon herniated to thorax. Left thoracoscopy was practised, finding a Bochdalek's hernia with presence of herniated descendent colon with a necrotic area, which was perforated and sealed. The herniated content was returned back in place, the diaphragmatic defect was corrected, and colostomy by laparoscopy was simultaneously performed. Her postoperative recovery was uneventful and she was discharged from the hospital. Combined thoracoscopy and laparoscopic surgery is effective in complicated cases of Bochdalek's hernia in adults, lessening surgical trauma and postsurgical morbidity.

Autofluorescence videothoracoscopy in exudative pleural effusions: preliminary results

Videothoracoscopy has been proven to be a safe tool to establish the diagnosis in >90% of patients with exudative pleural effusions of unknown origin. In the majority of patients with malignant pleural diseases, the endoscopic appearance of pleural lesions during white light thoracoscopy is suggestive of malignancy, but could be misleading in some cases. The aim of the present study was to estimate whether the combination of thoracoscopy with autofluorescence modalities would be useful to further improve the diagnostic accuracy of the conventional method. The present study displays early results of thoracoscopy performed consecutively with a normal light source and with autofluorescence light in 24 patients with exudative pleural effusion during 2003-2004. In all cases of malignant pleuritis (carcinoma or mesothelioma), the colour of the affected area of the pleura changed from white/pink to red (sensitivity 100%). However, in two cases of chronic pleuritis, a colour change from white/pink to orange/red was recorded (specificity 75%). In conclusion, the calculated positive predictive value of colour change for malignant pleuritis during autofluorescence thoracoscopy in this study was 92%. However, the clinical value of autofluorescence thoracoscopy in daily practice remains to be proven.

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of lung cancer

Background. This study seeks to assess the safety and usefulness of combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of patients with lung cancer. Methods. Ten consecutive patients with lung neoplasms were evaluated. Indications for this combined approach included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain histologic diagnosis by a single technique. Results. Histologic diagnosis was obtained in 6 patients without preoperative histologic typing. In 3 patients, in contrast with preoperative imaging studies, combined thoracoscopy and mediastinoscopy showed the resectability of the primary tumor and the absence of metastatic mediastinal lymph nodes. These findings were confirmed at thoracotomy. In 3 other patients prevascular lymph nodes metastases were found. They underwent neoadjuvant chemotherapy; at subsequent operation, a complete resection was possible. In the remaining four cases combined exploration proved definitive contraindications for operation (recognition of oat-cell carcinoma, n = 2; T4 status, n = 1; T3N2, n = 1). Conclusions. Combined video-assisted mediastinoscopy and video-assisted thoracoscopy seems to be a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread may be exhaustively evaluated. In patients with left lung cancer a complete exploration of the aortopulmonary window is possible.

Pleural lavage: a novel diagnostic approach for diagnosing exudative pleural effusion.

Patients with pleural effusions frequently present a diagnostic and therapeutic challenge. The diagnosis is based on the interpretation of the results of thoracentesis or pleural biopsy. When a malignant tumor metastasizes to the pleura, tumor cells can be seeded over the mesothelial surface or in the subserous layer. In the former situation, tumor cells are abundant in pleural fluid, but in the latter, few malignant cells are exfoliated into the pleural cavity, and microscopic deposits may not be visualized at thoracoscopy. Pleural lavage cytologic study at the time of thoracoscopy has not been studied. The purpose of this study was to assess the value of thoracoscopic pleural lavage as an adjuvant in the diagnostic workup of patients with exudative pleural effusions. Fifty patients with exudative pleural effusions were investigated by pleural fluid cytologic findings, Abram's pleural biopsy, thoracoscopy, and pleural lavage cytologic findings. After aspiration of all pleural fluid, 300 mL saline was instilled into the pleural cavity and then recovered for cytologic analysis. The final diagnoses were 32 malignant (64%), 15 tuberculous (30%), and 3 idiopathic (6%) effusions. In the malignant group, thoracoscopic biopsy had the highest yield (94%) followed by lavage cytologic analysis (84%), fluid cytologic analysis (62%), and biopsy with Abram's needle (50%). The sensitivity of combined thoracoscopy and lavage cytologic analysis was 96%. In the patients with tuberculous pleuritis, the yield from the pathologic examination of the biopsy specimen was 93% with thoracoscopy and 60% with the Abrams needle. The diagnostic yield with cytologic analysis on pleural lavage fluid is significantly higher than that on pleural fluid. This is probably because the cells in the lavage fluid are fresher and better preserved than those in the regular pleural fluid, which may have undergone degenerative changes, yielding false-negative results. Pleural lavage cytologic analysis should be performed in patients with suspected malignant pleural effusion who are subjected to diagnostic thoracoscopy, because it may provide additional information to thoracoscopic biopsy.

Combined thoracoscopy and mediastinoscopy for the evaluation of mediastinal lymph node metastasis in left upper lobe lung cancer: Nakanishi R, Mitsudomi T, Osaki T. Second Department of Surgery, School of Medicine, Univ. Occupat/Environmental Health, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu 807. J Cardiovasc Surg 1994;35:347–349

Cervical mediastinoscopy has an important but limited role in the evaluation of mediastinal adenopathy of the aorticopulmonary window in patients with left lung cancer. Thoracoscopy is another valuable diagnostic procedure in the assessment of mediastinal adenopathy. Combined thoracoscopic and mediastinoscopic evaluation may be more accurate for assessing mediastinal lymph node metastasis in left lung cancer than either procedure alone.

Thoracoscopic Ultrasonography of the Aortopulmonary Window

The role of thoracoscopy in staging lung cancer is unclear, but for assessment of the mediastinum, a combination of thoracoscopy and ultrasonography will permit the localization of enlarged lymph nodes or growth of the primary tumor into the mediastinum, defining their relationship with vascular structures and permitting their guided biopsy.