Subsequent Thoracotomy Research Articles

Anaesthetic management of post-PTCA cardiac tamponade from cath lab to cardiothoracic operating theater

Cardiac tamponade is a medical emergency characterized by the accumulation of fluid in the pericardial sac, exerting pressure on the heart and impairing its ability to pump blood effectively. This condition can result from various causes, including trauma, infection, malignancy, or complications of medical procedures such as percutaneous coronary interventions (PCI) like percutaneous transluminal coronary angioplasty (PTCA). The anaesthesiologists play a pivotal role as peri operative physicians in the catheterization laboratory and intensivists in the ICU in prompt recognition and intervention which is crucial to prevent hemodynamic collapse and improve patient outcomes. In this case, a female in her fifties with a history of previous PCI developed cardiac tamponade shortly after undergoing PTCA. Despite immediate stabilization attempts in the catheterization laboratory, the patient's condition deteriorated rapidly, necessitating emergency pericardiocentesis and subsequent thoracotomy for definitive management. The successful outcome of this case underscores the importance of early recognition, rapid intervention, and a multidisciplinary approach in managing cardiac tamponade post-PTCA.

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications.

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage. This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required. The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

Efficacy of uniportal video-assisted medical thoracoscopy in the management of multiloculated pleural infections: a retrospective study

BackgroundPleural infection is a serious medical issue for which the appropriate management is still controversial. Complicated (multiloculated) pleural infection usually requires invasive approach.ResultsA retrospective study that aims to assess the efficacy of uniportal video-assisted medical thoracoscopy in the management of complicated (multiloculated) pleural infections. Review of the charts of 37 patients with multiloculated pleural infections who were treated by uniportal video-assisted medical thoracoscopy. There were 30 (81.08%) males and 7 (18.91%) females, age ranging from 22 to 73 years, with a mean age of 49.13 ± 15. Etiology of empyema was complicated parapneumonic effusion in 25 patients (67.5%), tuberculosis in 10 patients (27.02%), and malignancy in 2 patients (5.40%). Treatment of multiloculated pleural infections by uniportal video-assisted medical thoracoscopy was successful in 33 patients (89.1%); those patients did not require any further intervention. Among successful cases, 25 patients (75.75%) showed complete resolution, and 8 patients (24.24%) showed partial success. Four patients (10.81%) required subsequent thoracotomy with decortication.ConclusionThe conclusion of the present study is that uniportal video-assisted medical thoracoscopy is a safe, valuable, and effective tool in the management of multiloculated pleural infections.

A two-step surgical approach combining sternotomy and subsequent thoracotomy for locally advanced lung cancers requiring both right upper lung resection and superior vena cava reconstruction.

Locally advanced lung cancers involving both right upper lung lobe and superior vena cava (SVC) requiring both lung resection and SVC reconstruction are generally deemed unresectable. However, previous evidence has proved that such patients could benefit from surgery if radical resection is achieved. Generally, a hemi-clamshell approach is adopted to complete such resection. However, it has the limitation of insufficient exposure of posterior mediastinum. Therefore, we introduced a two-step surgical approach combining sternotomy and thoracotomy for such lung cancers. A two-step surgical approach combining median sternotomy and subsequent posterolateral thoracotomy, via which radical lobectomy with systematic lymphadenectomy and SVC reconstruction could be successfully achieved, was described. We have performed such surgery via the two-step surgical approach combining median sternotomy and subsequent posterolateral thoracotomy in five patients from January 2017 to March 2018. All those patients achieved radical resection of the lung cancer with lobectomy and systematic lymphadenectomy and SVC reconstruction with artificial blood vessels, and had an uneventful postoperative recovery without any major complications. Our initial experience proved that this two-step surgical approach combining median sternotomy and subsequent posterolateral thoracotomy was safe and feasible for locally advanced lung cancers requiring both lung resection and SVC reconstruction.

Empyema and lung abscess: An unusual presentation of pulmonary actinomycosis

Actinomyces spp. are an infrequent cause of pulmonary infections. Actinomyces spp. comprise part of the normal flora of the oral cavity and gastrointestinal tract. A. meyeri is especially known for pulmonary involvement and disseminated disease. The authors present a case of a polymicrobial pulmonary abscess containing A. meyeri. The patient was a 58-year-old man with a history of coronary artery disease, alcohol abuse and hypertension. He presented with progressive dyspnea and cough productive of grey-colored foul smelling sputum. Upon admission, a chest computed tomographic (CT) scan revealed a right-lower-lobe lung abscess, with an associated loculated empyema. The following day, the patient underwent a thoracostomy with chest tube placement. The chest tube drained several hundred milliliters of purulent pleural fluid, but a follow up chest CT showed little change in the size of the underlying empyema. A subsequent thoracotomy with decortication was performed, which evacuated 100 ml of thick purulent fluid. Fourteen days after admission, the patient was discharged on a 6- to 12-week course of intravenous penicillin G, followed by a 6-month course of oral penicillin V.

Operative Treatment of Spontaneous Pneumothorax and Persistent Air Leaks – The Thoracoscopic Approach

Background: Spontaneous pneumothoraces are common thoracic surgical problems and when complicated by recurrences and persistent air leaks are often difficult to treat. While conservative non-operative methods were favored in the past, thoracoscopy has made operative treatment more successful, easier and less painful. We reviewed our experience withthoracoscopic management of spontaneous pneumothorax. Methods: We analyzed the retrospective data from the patients who received Video-Assisted Thoracoscopic Surgery for spontaneous pneumothoraces from January 2012 to January 2013 at Manmohan Cardio-thoracic Vascular and Transplant Center. Results: The male to female ratio was 6:1 with mean age 33 years (minimum17 years to maximum70 years). The ratio of primary spontaneous to secondary spontaneous was 5:2. Seventeen of 21 patients had air leaks at operation. Seven of 15 patients with primary spontaneous and 4/6 with secondary spontaneous had prior two or more episodes of pneumothorax. Blebs/ bullae were found in 18/21 patients. In 9/18 patients, the bullae/blebs were stapled while in seven, they were plicated. Only pleurodesis was done in the remaining patients. Additional procedures in the form of decortications were required in three. The chest tube was removed by the second post operative day in 13/21 patients. Prolonged chest tube was required in three patients (persistent leak in two and collection in one patient). One patient needed a subsequent thoracotomy and decortication. Conclusion: Thoracoscopic approach to spontaneous pneumothoraces and persistent air leaks is feasible and safe. Plication of bullae/ blebs can be a viable alternative when stapling devices are not available. Nepal Journal of Medical Sciences | Volume 03 | Number 01 | January-June 2014 | Page 14-18 DOI: http://dx.doi.org/10.3126/njms.v3i1.10343

Thoracoscopic Versus Open Pulmonary Metastasectomy: A Prospective, Sequentially Controlled Study

Patients with limited metastatic disease in the lung may benefit from metastasectomy. Thoracotomy is considered the gold standard, and video-assisted thoracoscopic surgery (VATS) is controversial because nonimaged nodules may be missed when bimanual palpation is restricted. Against guideline recommendations, metastasectomy with therapeutic intent is now performed by VATS by 40% of thoracic surgeons surveyed. The evidence base for optimal surgical approach is limited to case series and registries, and no comparative surgical studies were observer blinded. Patients considered eligible for pulmonary metastasectomy by VATS prospectively underwent high-definition VATS by one surgical team, followed by immediate thoracotomy with bimanual palpation and resection of all palpable nodules by a second surgical team during the same anesthesia. Both surgical teams were blinded during preoperative evaluation of CT scans and during surgery. Primary end points were number and histology of nodules detected. During a 12-month period, 37 patients were included. Both surgical teams observed exactly 55 nodules suspicious of metastases on CT scans. Of these, 51 nodules were palpable during VATS (92%), and during subsequent thoracotomy 29 additional nodules were resected: Six (21%) were metastases, 19 (66%) were benign lesions, three (10%) were subpleural lymph nodes and one was a primary lung cancer. Modern VATS technology is increasingly used for pulmonary metastasectomy with therapeutic intent, but several nonimaged, and therefore unexpected, nodules are frequently found during subsequent observer-blinded thoracotomy. A substantial proportion of these nodules are malignant, and, despite modern imaging and surgical technology, they would have been missed if VATS was used exclusively for metastasectomy with therapeutic intent.

Pyopneumothorax Secondary to Aspergillus Infection: A Case Report

A 32 -year- old male presented with complaints of fever, dry cough, breathlessness and right sided chest pain of two months duration. Chest radiograph showed right sided hydropneumothorax which revealed frank pus on diagnostic thoracocentesis, for which tube thoracostomy was done. Despite vigorous broad spectrum antibiotic coverage, postural drainage and chest physiotherapy, there was no clinical improvement. Further work up included serology, pleural fluid culture, closed as well as thoracoscopic guided pleural biopsy revealed growth of Aspergillus fumigatus. Patient was prescribed antifungal medication (Voriconazole) and subsequent thoracotomy with right sided pneumonectomy showed good clinical recovery.

Extended cervical mediastinoscopy: mature results of a clinical protocol for staging bronchogenic carcinoma of the left lung

The objective of this study is to evaluate the accuracy of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma (BC) of the left lung based on our updated experience. From 1998 to 2003, 89 patients underwent routine ECM for staging of BC of the left lung. In 2004, routine positron emission tomography (PET) was included in our staging protocol and ECM was reserved for those with positive mediastinal or hilar PET images, large lymph nodes on computed tomography (CT) scan or central tumours. Following this protocol, from 2004 to 2010, we performed 132 selective ECM. ECM was considered positive when metastatic nodes or tumour involvement directly in the subaortic or para-aortic regions was confirmed pathologically. Patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection (SND). Two hundred and twenty-one ECMs were performed from 1998 to 2010 (89 routine and 132 selective). In the routine ECM protocol, four cases were positive and thoracotomy was contraindicated. The remaining 85 patients were operated and five had nodal disease in subaortic (LN5) or para-aortic (LN6) stations. In the selective ECM protocol (n=188), 132 patients underwent ECM and in 19 it was positive; the remaining 113 patients underwent thoracotomy and SND found involved LN5 or LN6 in six patients; the other 56 patients underwent direct thoracotomy and four had positive LN5 or LN6. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ECM were 0.67, 1, 1, 0.94 and 0.95, respectively. The staging values of routine/selective ECM protocols were 0.44/0.65, 1/1, 1/1, 0.94/0.94 and 0.94/0.95, respectively. Selective ECM protocol according to CT and PET findings has high negative predictive value and accuracy. Therefore, its selective use is recommended because it saves around 30% ECM without decreasing staging values of the current protocol.

Management of esophageal atresia with a tracheoesophageal fistula complicated by gastric perforation

Gastric perforations generally develop in neonates with esophageal atresia (EA) and a tracheoesophageal fistula (TEF), requiring preoperative mechanical ventilation. To the best of our knowledge, spontaneous gastric perforation in patients who have not been treated with mechanical ventilation has not been described in the literature. There is also no current consensus or treatment protocol available for the management of these patients. Over a period of 6 years, six patients with EA and TEF presented with gastric perforation at our center. We studied the clinical presentation, initial resuscitation, surgical management, and outcome of these six patients. Out of the six patients, five were treated with initial flank drain insertion for peritoneal decompression. In all of the patients, a thoracotomy was performed first, followed by a laparotomy for closure of the stomach perforation. Four of the six patients survived and were discharged uneventfully. Two patients died of sepsis. Early feeding was established in all of the patients. Spontaneous gastric perforation can occur in patients with EA and TEF even without mechanical ventilation. Initial stabilization with peritoneal drain insertion and subsequent thoracotomy for esophageal anastomosis followed by laparotomy for stomach repair, both done in a single sitting, should be the ideal management of such patients.

Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) for Staging of Non-Small-Cell Lung Cancer (NSCLC)

Introduction: The aim of the study is to analyze diagnostic yield of the new surgical technique — the Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) in preoperative staging of Non-Small-Cell Lung Cancer (NSCLC). Material and methods: Operative technique included 5–8 cm collar incision in the neck, elevation of the sternal manubrium with a special retractor, bilateral visualization of the laryngeal recurrent and vagus nerves and dissection of all mediastinal nodal stations except of the pulmonary ligament nodes (station 9). Results: 698 patients (577 men, 121 women), of mean age 62.8 (41–79) were operated on from 1.1.2004 to 31.1.2010, including 501 squamous-cell carcinomas, 144 adenocarcinomas, 25 large cell carcinomas and 28 others. Mean operative time was 128 min. (45 to 330 min.) and 106.5 min. in the last 100 patients. 30-day mortality was 0.7% (unrelated causes) and morbidity 6.6%. The mean number of dissected nodes during TEMLA was 37.9 (15 to 85). Metastatic N2 and N3 nodes were found in 152/698 (21.8%) and 26/698 patients (3.7%), respectively. Subsequent thoracotomy was performed in 445/ 513 patients (86.7%) after negative result of TEMLA. During thoracotomy, omitted N2 was found in 7/445 (1.6%) patients. Sensitivity of TEMLA in discovery of N2–3 nodes was 96.2%, specificity was 100%, accuracy was 99,0%, Negative Predictive Value (NPV) was 98.7% and Positive Predictive Value (PPV) was 100%. Conclusions: TEMLA is a new minimally invasive surgical procedure providing unique possibility to perform very extensive, bilateral mediastinal lymphadenectomy with very high diagnostic yield in staging of NSCLC.

TRANSCERVICAL EXTENDED MEDIASTINAL LYMPHADENECTOMY (TEMLA) FOR STAGING OF NON-SMALL-CELL LUNG CANCER (NSCLC)

The aim of the study is to analyze diagnostic yield of the new surgical technique--the Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) in preoperative staging of Non-Small-Cell Lung Cancer (NSCLC). Operative technique included 5-8 cm collar incision in the neck, elevation of the sternal manubrium with a special retractor, bilateral visualization of the laryngeal recurrent and vagus nerves and dissection of all mediastinal nodal stations except of the pulmonary ligament nodes (station 9). 698 patients (577 men, 121 women), of mean age 62.8 (41-79) were operated on from 1.1.2004 to 31.1.2010, including 501 squamous-cell carcinomas, 144 adenocarcinomas, 25 large cell carcinomas and 28 others. Mean operative time was 128 min. (45 to 330 min) and 106.5 min. in the last 100 patients. 30-day mortality was 0.7 % (unrelated causes) and morbidity 6.6%. The mean number of dissected nodes during TEMLA was 37.9 (15 to 85). Metastatic N2 and N3 nodes were found in 152/698 (21.8%) and 26/698 patients (3.7%), respectively. Subsequent thoracotomy was performed in 445/513 patients (86.7%) after negative result of TEMLA. During thoracotomy, omitted N2 was found in 7/445 (1.6%) patients. Sensitivity of TEMLA in discovery of metastatic N2-3 nodes was 96.2 %, specificity was 100%, accuracy was 99,0%, Negative Predictive Value (NPV) was 98.7 % and Positive Predictive Value (PPV) was 100%. TEMLA is a new minimally invasive surgical procedure providing unique possibility to perform very extensive, bilateral mediastinal lymphadenectomy with very high diagnostic yield in staging of NSCLC Pneumonol.

Surgical Management of the Subdiaphragmatic Mass: A Sequential Combined Approach With Laparoscopy Followed by Posterior Thoracotomy

Recurrent ovarian cancer in the upper abdomen involving the liver parenchyma and diaphragmatic muscle traditionally requires a major abdominal surgical procedure; this involves pubis to xyphoid incision and complete mobilization of the liver. We present a strategy for evaluating 4 cases with apparently isolated recurrence to the diaphragm and liver approached by a sequential 2-phase procedure, involving diagnostic laparoscopy and subsequent posterior lateral thoracotomy. Preliminary diagnostic laparoscopy was performed to distinguish candidates for either definitive laparoscopic treatment or posterior thoracotomy. Two patients with disease confined to the diaphragm were successfully treated by laparoscopy alone, whereas full-thickness diaphragmatic resection and liver metastasis excision with cavitational ultrasonic surgical aspirator was performed in the other 2 patients. Argon beam coagulation was used to control local hemostasis and to fulgurate any possible residual tumor at the margin of resection. This is a multidisciplinary approach that is technically feasible and safe, requiring a short hospital stay.

Is there a role for surgery in stage IIIA-N2 non-small cell lung cancer?

The role of surgery in stage IIIA-N2 non-small cell lung cancer (NSCLC) remains controversial. Most important prognostic factors are mediastinal downstaging and complete surgical resection. Different restaging techniques exist to evaluate response after induction therapy and these are subdivided into non-invasive, invasive and alternative or minimally invasive techniques. In contrast to imaging or functional studies, remediastinoscopy provides pathological evidence of response after induction therapy. Although technically more challenging than a first procedure, remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information. An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasound to obtain an initial proof of mediastinal nodal involvement. Mediastinoscopy is subsequently performed after induction therapy to evaluate response. In this way, a technically more difficult remediastinoscopy can be avoided. Stage IIIA-N2 NSCLC represents a heterogenous spectrum of locally advanced disease and different subsets exist. When N2 disease is discovered during thoracotomy after negative, careful preoperative staging a resection should be performed if this can be complete. Postoperative radiotherapy will decrease local recurrence rate but not overall survival. Adjuvant chemotherapy increases survival and is presently recommended in these cases. Most patients with pathologically proven N2 disease detected during preoperative work-up will be treated by induction therapy followed by surgery or radiotherapy. In two large, recently completed, phase III trials there was no difference in overall survival between the surgical and radiotherapy arm, but in one trial there was a difference in progression-free survival in favor of the surgical arm. In the surgery arm the rate of local recurrences was also lower in both trials. Surgical resection may be recommended in those patients with proven mediastinal downstaging after induction therapy who can preferentially be treated by lobectomy. Pneumonectomy has a significantly higher mortality and morbidity rate, especially after induction chemoradiotherapy. Patients with bulky N2 disease are mostly treated with combined chemoradiotherapy although the precise treatment scheme has not been determined yet.

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma of the left lung

To evaluate the technical feasibility and the sensitivity, specificity and accuracy of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma (BC) of the left lung. From 1998 to 2003, 89 patients underwent routine ECM for staging of BC of the left lung. In 2004, positron emission tomography (PET) was included in our staging protocol and ECM was reserved for those with positive mediastinal or hilar PET images, large lymph nodes on computed tomography (CT) scan or central tumours. From 2004 to 2007 we performed selective ECM in 67 patients. ECM was considered positive when metastatic nodes or tumour involvement directly in the subaortic or para-aortic regions was confirmed pathologically. One hundred and forty-three patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection. Pathological findings were reviewed and staging values were calculated. One hundred and fifty-six patients underwent ECM (89 routine and 67 selective). In 13, ECM was positive and thoracotomy was contraindicated. The rest of the patients were operated. We performed 88 lobectomies, 34 pneumonectomies, 6 wedge resections, 13 exploratory thoracotomies and 2 parasternal mediastinotomies. Lymphadenectomy specimens showed tumour involvement of subaortic lymph nodes in 8 patients. Complication rate was 2%: two cases of mediastinitis, one ventricular fibrillation, and one superficial surgical wound infection. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of routine/selective ECM were: 0.45/0.75, 1/1, 1/1, 0.94/0.95, 0.94/0.95, respectively. ECM is a feasible staging technique that allows ruling out subaortic and para-aortic nodal disease with high negative predictive value, accuracy and sensitivity. Its indication based on the CT and PET findings seems more advisable that its routine use to stage bronchogenic carcinoma of the left lung.

A second mediastinoscopy: how to decide and how to do it?☆

Specific indications for a second or remediastinoscopy include an inadequate first procedure, metachronous second primary or recurrent lung cancer, lung cancer after unrelated disease, and restaging after induction therapy. Nowadays, restaging is the most frequent indication for remediastinoscopy. Only patients with proven mediastinal downstaging will benefit from a subsequent surgical resection. In contrast to imaging or functional studies, remediastinoscopy provides pathological evidence of response after induction therapy. Although technically more challenging than a first procedure, remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information. Technically, mediastinal dissection is usually started at the left paratracheal side to avoid the innominate artery. Under the aortic arch, dissection proceeds in the pretracheal plane until the subcarinal nodes are reached. Sensitivity of a second mediastinoscopy is lower than a first procedure but in the most recent series it is higher than 70% with an accuracy around 85%. Survival also depends on the findings of remediastinoscopy, patients with persisting mediastinal involvement having a poor prognosis. An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasound to obtain an initial proof of mediastinal nodal involvement. Mediastinoscopy is subsequently performed after induction therapy to evaluate response. In this way, a technically more difficult remediastinoscopy can be avoided.

Does video-mediastinoscopy improve the results of conventional mediastinoscopy?☆

Despite new technologies, mediastinoscopy remains the gold standard for mediastinal staging of lung cancer even though the procedure is not standardised. Introduction of video-mediastinoscopy (VM) may help to overcome this problem as it better visualises the anatomy and allows a more uniform dissection than conventional mediastinoscopy (CM). Does the use of VM result in more lymph node tissue, higher accuracy and lower complication rates as compared to CM? All mediastinoscopies from June 2003 to December 2005 were analysed. In a protocol surgeons documented location of lymph node stations, number of lymph nodes resected or biopsied and technique (VM or CM). Two groups were created for analysis: group 1 (n=366) consisting of all mediastinoscopies was reviewed for complication rates; group 2 included all patients with lung cancer who had a pN0 status by mediastinoscopy and underwent subsequent thoracotomy (n=171). This group was studied for the number of lymph nodes resected or biopsied according to the technique (VM or CM), on accuracy and negative predictive value. Of 366 mediastinoscopies, 132 were CM (36.1%) and 234 VM (63.9%). Complications occurred in 17 patients (4.6%): 9 recurrent laryngeal nerve palsies (VM 2.1%, CM 3.0%), 5 mediastinal enlargement on routine chest radiography interpreted as postoperative bleeding (VM 0.9%, CM 2.3%), pneumonia (1), intraoperative laceration of the pleura (1) and main bronchus (1), both corrected during the procedure (all VM 1.3%). No intraoperative haemorrhage or death occurred. VM resected more lymph nodes (mean 8.1, range 3-25) then CM (mean 6.0, range 3-11), for all mediastinoscopies the mean lymph node yield was 7.6 (range 3-25). Comparison of lymphadenectomy via thoracotomy in patients classified pN0 by mediastinoscopy (n=171) showed an accuracy of 87.9% for VM versus 83.8% for CM (85.8% for all mediastinoscopies) with a negative predictive value of 0.83 for VM and 0.81 for CM (0.82 for all mediastinoscopies). This study demonstrates that in comparison with CM, VM routinely yields more lymph nodes with fewer complications with a tendency towards better accuracy and negative predictive value. For these reasons, we believe that VM should replace CM as the method of choice. Furthermore VM would allow standardisation, thereby having an advantage in comparison to the less invasive newer staging techniques. This way mediastinoscopy could remain the gold standard despite its invasiveness.

Transcervical Extended Mediastinal Lymphadenectomy: Results of Staging in Two Hundred Fifty-Six Patients with Non-Small Cell Lung Cancer

Transcervical extended mediastinal lymphadenectomy (TEMLA) is a new surgical procedure for staging of the mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC). The operation is performed through the 5- to 8-cm collar incision in the neck and enables complete removal of all mediastinal nodal stations except for the pulmonary ligament nodes (station 9) and the most distal left paratracheal nodes (station 4L). Generally, TEMLA is an open procedure performed partly with mediastinoscopy-assisted and videothoracoscopy-assisted techniques. Operative technique of TEMLA includes elevation of the sternal manubrium with a special retractor and bilateral visualization of the laryngeal recurrent and vagus nerves. From January 1, 2004 to November 15, 2005, TEMLA was performed in 256 patients. Length of operation was 80 to 330 minutes (mean, 161 minutes). Complication of TEMLA occurred in 11.3% of patients with temporary laryngeal nerve palsy in 6 of 256 patients (2.3%) and permanent nerve palsy in 2 of 256 patients (0.8%). The number of dissected nodes during TEMLA was 15 to 85 (mean, 38.9). N2-3 nodes were found in 80 patients (31.3%). During subsequent thoracotomy, omitted N2 nodes were found in 5 of 138 patients, and omitted normal mediastinal nodes were found in 13 of 138 patients (9.4%). Sensitivity of TEMLA in discovery of N2-3 nodes was 94.1%, specificity was 100%, accuracy was 98%, negative predictive value was 97.2%, and positive predictive value was 100%. Preliminary results may suggest some therapeutic impact for patients who underwent TEMLA and subsequent R0 resection, with a 77.2% survival rate after the mean 24-month follow-up period.

Remediastinoscopy

Remediastinoscopy

Left Ventricular Rupture during Closed-chest Cardiopulmonary Resuscitation after Pneumonectomy - A case report -

We report a case of circulatory collapse and cardiac arrest immediately after the patient was turned from the lateral decubitus position to the supine position following left pneumonectomy. Closed-chest resuscitation with medical and fluid interventions were inadequate. Emergency chest showed the deviation of heart to the left side and blunted apex. Left ventricular rupture during resuscitation was found subsequent thoracotomy. This rupture and inadequacy of closed-chest resuscitation were felt to be associated with the operative pneumonectomy and pericardiotomy.