Thoracic Interventions Research Articles

Complications in CT-guided Procedures: Do We Really Need Postinterventional CT Control Scans?

The aim of this study is twofold: to determine the complication rate in computed tomography (CT)-guided biopsies and drainages, and to evaluate the value of postinterventional CT control scans. Retrospective analysis of 1,067 CT-guided diagnostic biopsies (n = 476) and therapeutic drainages (n = 591) in thoracic (n = 37), abdominal (n = 866), and musculoskeletal (ms) (n = 164) locations. Severity of any complication was categorized as minor or major. To assess the need for postinterventional CT control scans, it was determined whether complications were detected clinically, on peri-procedural scans or on postinterventional scans only. The complication rate was 2.5 % in all procedures (n = 27), 4.4 % in diagnostic punctures, and 1.0 % in drainages; 13.5 % in thoracic, 2.0 % in abdominal, and 3.0 % in musculoskeletal procedures. There was only 1 major complication (0.1 %). Pneumothorax (n = 14) was most frequent, followed by bleeding (n = 9), paresthesia (n = 2), material damage (n = 1), and bone fissure (n = 1). Postinterventional control acquisitions were performed in 65.7 % (701 of 1,067). Six complications were solely detectable in postinterventional control acquisitions (3 retroperitoneal bleeds, 3 pneumothoraces); all other complications were clinically detectable (n = 4) and/or visible in peri-interventional controls (n = 21). Complications in CT-guided interventions are rare. Of these, thoracic interventions had the highest rate, while pneumothoraces and bleeding were most frequent. Most complications can be detected clinically or peri-interventionally. To reduce the radiation dose, postinterventional CT controls should not be performed routinely and should be restricted to complicated or retroperitoneal interventions only.

Transoral endoscopic surgery versus conventional thoracoscopic surgery for thoracic intervention: safety and efficacy in a canine survival model

Transoral endoscopic surgery has been shown to be feasible and safe in both humans and animal models. The purpose of this study was to evaluate the safety and efficacy of transoral and conventional thoracoscopy for thoracic exploration, surgical lung biopsy, and pericardial window creation. The animals (n = 20) were randomly assigned to the transoral endoscopic approach group (n = 10) or conventional thoracoscopic approach group (n = 10). Transoral thoracoscopy was performed with a flexible bronchoscope via an incision over the vestibulum oris. In conventional thoracoscopy, access to the thoracic cavity was obtained through a thoracic incision. Surgical outcomes (body weight, operating time, operative complications, and time to resumption of normal diet), physiologic parameters (respiratory rate, body temperature), inflammatory parameters [white blood cell (WBC) counts and C-reactive protein (CRP)], and pulmonary parameters (arterial blood gases) were compared for both procedures. The surgical lung biopsy and pericardial window creation were successfully performed in all animals except one animal in the transoral group. There was no significant difference in operating times between the groups. The increase in WBC in the transoral thoracoscopy group was significantly smaller on postoperative day 1 than in the conventional thoracoscopy group (p = 0.0029). The transoral group had an earlier return to preoperative body temperature (p = 0.041) and respiratory rate (p = 0.045) on day 7. With respect to pulmonary parameters, there was no significant difference in blood pH, pCO2, or PaCO2 between the transoral and transthoracic groups. All animals survived without complications 14 days after surgery. This study demonstrated that the transoral approach was comparable to conventional thoracoscopic surgery for lung biopsy and pericardial window creation in terms of safety and efficacy.

Endovascular Stent Graft Repair for Thoracic Aortic Aneurysms: The History and the Present in Japan

Stent-grafts for endovascular repair of thoracic aortic aneurysms have been commercially available for more than ten years in the West, whereas, in Japan, a manufactured stent-graft was not approved for the use until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices used in most cases. Many researchers have continued to develop their homemade devices. We have participated in joint design and assessment efforts with a stent-graft manufacturer, focusing primarily on fenestrated stent-grafts used in repairs at the distal arch, a site especially prone to aneurysm. In March 2008, TAG (W.L. Gore & Associates, Inc., Flagstaff, Arizona, USA) was approved as a stent graft for the thoracic area first in Japan, which was major turning point in treatment for thoracic aortic aneurysms. Subsequently, TALENT (Medtronic, Inc., Minneapolis, Minnesota, USA) was approved in May 2009, and TX2 (COOK MEDICAL Inc., Bloomington, Indiana, USA) in March 2011. Valiant as an improved version of TALENT was approved in November 2011, and TX2 Proform as an improved version of TX2 began to be supplied in October 2012. These stent grafts are excellent devices that showed good results in Western countries, and marked effectiveness can be expected by making the most of the characteristics of each device. A clinical trial in Japan on Najuta (tentative name) (Kawasumi Labo., Inc., Tokyo, Japan) as a line-up of fenestrated stent grafts that can be applied to distal arch aneurysms showing a high incidence, and allow maintenance of blood flow to the arch vessel was initiated. This trial was completed, and Najuta has just been approved in January of 2013 in Japan, and further development is expected. In the U.S., great efforts have recently been made to develop and manufacture excellent stent grafts for thoracic aneurysms, and rapid progress has been achieved. In particular, in the area of the aortic arch, in which we often experience aneurysmal change, but there are no commercially available devices which are urgently needed. Companies are competing keenly to develop devices. To our knowledge, more than 4 manufacturers are involved in the development of functionally new stent grafts in this area. The introduction of branched stent grafts may not be faraway.

Misdiagnosis of pneumothorax by ultrasonography after central venous catheterization in a patient with pleural adhesion

Misdiagnosis of pneumothorax by ultrasonography after central venous catheterization in a patient with pleural adhesion

Anästhesie bei Eingriffen an Herz, Thorax und den großen Gefäßen, Teil 2 – Endoskopische Thoraxeingriffe und endovaskuläre Aortenstentanlage

Despite the ongoing further development of high definition imaging techniques (CT, MRI), mediastinoscopy and thoracoscopy remain essential instruments e.g. for extracting mediastinal lymph nodes allowing further histological diagnostics, or increasingly complex thoracoscopic procedures. Furthermore, in the course of the development of endoscopic thoracic and percutaneous interventions, the therapy of thoracic aortic aneurysms is increasingly the domain of endovascular procedures. In the second part of this review the anaesthesiological procedure and specialties concerning endoscopic thoracic interventions and percutaneous aortic aneurysm repair (EVAR) will be described.

Estimation of Extravascular Lung Water During and After Extensive Thoracic Interventions

Background. Postoperative lung injury is a cause of most fatal outcomes after extensive lung resections. Death rates due to postpneumonectomy pulmonary edema have remained unchanged within the past 20 years and are currently tending to 100%. Objective: to make prolonged lung edema monitoring in patients after extensive thoracic interventions. Subjects and methods. The observational study covered 27 patients who had undergone pneumonectomy (PE) (n=16) or lung resection (n=11). Invasive monitoring by the PiCCOplus system was performed to examine the systemic and pulmonary hemodynamics of all the patients during surgery and within 48 postoperative hours. Results. PE rather than lung resection was accompanied by a significant reduction in the extravascular lung water index (EVLWI). Most patients who had undergone PE were found to have a subclinical increase in EVLWI 36-48 hours after termination of the intervention. Conclusion. In this observational clinical study, isolated thermodilution showed an immediate decrease in EVLWI after PE and its increase at 36—48 postoperative hours. Lobar or segmental interventions failed to cause significant changes in EVLWI in the perioperative period. Key words: pneumonectomy, lung resection, lung edema, extravascular lung water, acute lung injury.

The lateral decubitus position improves transoral endoscopic access to the posterior aspects of the thorax

The success of natural orifice transluminal endoscopic surgery (NOTES) depends on an adequate exploration of surgical regions. Currently, limited data are available regarding the optimal position for the NOTES approach for thoracic surgery. This study therefore aimed to evaluate the effectiveness of transoral thoracic exploration in a canine model placed in a lateral decubitus position. A total of 14 dogs were used in this study. Transoral thoracoscopy was performed using a custom-made metal tube via an incision over the vestibular incision with the animal in a supine position. After thoracic exploration, the animal was placed in a lateral decubitus position. The thoracic intervention (surgical lung biopsy, pericardial window creation, and dorsal sympathectomy) was performed by passing a flexible bronchoscope through the lumen of a metal tube. The mean operative time for this procedure was 70 min (range 45-100 min). For 12 dogs, all procedures were completed without major complications. However, for one dog, the exploration of the thoracic cavity was incorrect (the right lower lobe had been misinterpreted as the left lower lobe). Another dog had minor bleeding because of an intercostal artery injury that occurred during sympathectomy. The posterior aspect of the thoracic cavity can be exposed via a transoral approach with the animal in a lateral decubitus position. This approach may be considered as an adjuvant to the supine approach, in which exploration of the posterior thoracic cavity is restricted.

Accuracy of transthoracic ultrasound for the detection of pleural adhesions

In the era of minimally invasive surgery, preoperative detection of pleural adhesions can be very useful for the assessment of surgical approach, because pleural adhesions are the main contraindication to video-assisted thoracoscopy. The aim of this study was to assess the sensitivity and specificity of transthoracic ultrasound in the detection of pleural adhesions prior to thoracic surgery. From February 2010 to January 2011, 142 consecutive patients (male, 98; female, 44; age range, 36-83 years, mean age, 63.4 years) undergoing surgical thoracic intervention (except for pneumothorax) were preoperatively scanned by two different surgeons. According to thoracic wall projections of lung segments, we created a nine-region topographic map, in which every pulmonary area was scanned to assess the presence or the absence of 'gliding sign' (lesion-by-lesion analysis). During operations the surgeon, blinded to the prediction, confirmed or excluded each suspected adhesion or documented other adhesions not previously identified. A total of 1192 predictions were made. Ultrasound predictions were confirmed 1124 times and refuted 68 times. Sensitivity was 80.6% (95% confidence interval, 0.740-0.872) and specificity 96.1% (95% confidence interval, 0.949-0.973). The positive predictive value was 73.2% and the negative predictive value was 97.4%. Transthoracic ultrasound is an effective method for predicting pleural adhesions before thoracic surgery in experienced hands. Its safety, feasibility and low cost make it a useful method for the planning of minimally invasive surgical interventions.

Tension Pneumatocele due toEnterobacter gergoviaePneumonia: A Case Report

Pneumatocele formation is a known complication of pneumonia. Very rarely, they may increase markedly in size, causing cardiorespiratory compromise. Many organisms have been implicated in the pathogenesis of this disease; however, this is the first report of tension pneumatocele resulting from Enterobacter gergoviae pneumonia. We report a case of a 3-month-old Nigerian male child who developed two massive tension pneumatoceles while on treatment for postpneumonic empyema due to Enterobacter gergoviae pneumonia. Tube thoracostomy directed into both pneumatocele resulted in complete resolution and recovery. Enterobacter gergoviae is a relevant human pathogen, capable of causing complicated pneumonia with fatal outcome if not properly managed. In developing countries where state-of the-art radiological facilities and expertise for prompt thoracic intervention are lacking, there is still room for nonoperative management of tension pneumatocele especially in very ill children.

Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage

Background Intrathoracic contamination from esophageal perforation, staple line dehiscence, or trauma can be a preterminal event. In our institution, covered self-expanding metal stents have been used aggressively in the management of esophageal leak, but their use remains controversial. The primary objective of this study was to evaluate the efficacy of esophageal salvage using stents to assist in the management of intrathoracic esophageal leakage. Methods Over 38 months, 63 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment and identified using a prospective database. Results Fifty-six patients were managed with endoscopic stenting as primary therapy and 30 of those patients required a thoracic intervention after stenting. Seven of these patients required esophageal diversion after stent failure. Thirty-day mortality was 10% in the patients with intrathoracic contamination. Conclusions We suggest that the use of covered self-expanding metal stents in patients with intrathoracic leak after esophageal perforation is safe and offers esophageal salvage in 77% regardless of time of presentation.

Reducing length of stay through the use of ambulatory chest drains and nurse-led follow-up

This paper explores the use of ambulatory chest drains to promote earlier discharge. The insertion of an underwater seal chest drain is routine following thoracic surgical intervention to facilitate post operative lung expansion. This generally takes between 3-5 days. Once the lung has expanded, the drain is removed and the patient discharged. In a minority of patients, namely those with a persistent air leak, recurrent malignant pleural effusion or empyema, lung expansion is slow and consequently discharge is delayed. Many of these patients are able to tolerate an ambulatory device such as the Portex bag or PleurX catheter. A clinic was developed to enable followup on a regular basis by a specialist nurse. Outpatient visits, regular telephone support and input from community nursing teams allowed management of this patient group. Audit of the clinic revealed a reduction in length of hospital stay (to 7.3 days) for patients with prolonged air leaks following surgery

Minimally invasive esophagectomy: thoracoscopic esophageal mobilization for esophageal cancer with the patient in prone position

Surgical resection is the mainstay treatment for resectable esophageal cancer. Minimally invasive esophagectomy is performed with increasing frequency and proves to be a safe and effective surgical alternative to the open technique. Minimally invasive esophagectomy using thoracoscopic esophageal mobilization with the patient in prone position seems to offer some advantages with regard to surgeon ergonomics and clinical outcome. Between July 2005 and September 2010, 46 patients (35 men and 11 women) underwent minimally invasive esophagectomy in the prone position at the authors' institution. Three patients had previously undergone a thoracic intervention (one patient had previously undergone left pneumonectomy because of lung cancer). The preoperative indication was squamous cell carcinoma for 35 patients and adenocarcinoma for 11 patients. In one case, the histology of the biopsy samples showed a squamous cell carcinoma with neuroendocrine differentiation. Neoadjuvant treatment was administered to 15 patients. All 46 patients underwent esophagectomy using minimally invasive thoracic mobilization of the esophagus with the patient in prone position. The abdominal stage of intervention was performed by laparoscopy for 37 patients and by laparotomy for 9 patients. No thoracotomic conversion was performed. In all cases, a cervical end-to-side anastomosis was performed using a circular stapler. The mean operative time was 263 min. The median intensive care unit stay was 2 days, and the median postoperative hospital stay was 15 days. The mean number of procured lymph nodes was 13. The perioperative morbidity rate was 37%, and the perioperative mortality rate was 4.4%. Minimally invasive esophagectomy is safe and technically feasible. It entails a lower mortality rate and a shorter hospital stay than those reported in most open series. Thoracoscopy with the patient in prone position offers results comparable with those obtained using other minimally invasive techniques regarding the number of procured lymph nodes. This technique shows considerable advantages such as improved surgeon ergonomics, increased operative field exposure, and satisfactory respiratory results.

Comment to the article: Diaphragmatic patch: A useful adjunct in surgical treatment of recurrent catamenial hemothorax

The present work reviews the catamenial hemothorax and its relation to two potential clinical cases. Hemothorax is a condition usually associated to thoracic trauma, iatrogenesis, pneumothorax, and malignant or infectious pleural disease. Apart from these clinical entities, the presence of hemothorax is not frequent and its etiology is usually difficult to ascertain. Thoracic endometriosis1,2 is one of the rare entities that can be responsible for the presentation of a hemothorax, and the diagnosis is relatively easy when endometriosis foci are found within the thoracic cavity. More frequently, hemothorax is clinically diagnosed in female patients with abdominal endometriosis presenting pneumothorax and/or hemothorax associated with the end phase of the menstrual cycle.2,3 Other cases are usually labelled as idiopathic cases. Regarding the treatment, the use of drainage alone can be sufficient; as a matter of fact, autologous blood was injected in the pleural space as the treatment for pneumothorax since it facilitates the development of pleural adherences.4,5 Cleaning of pleural cavity through videothoracoscopy, combined with pleural and diaphragmatic abrasion, could facilitate the diagnosis and, at the same time, solve the problem.2,3 In case of relapse, total or partial parietal pleurectomy could be a more aggressive option for the management of this entity. In every case, pleural examination and lung palpation should be done in order to identify the presence of lung bullas, endometriosis foci or nodules that should be resected for diagnosis and treatment purposes. The diaphragm should be carefully inspected for the identification and closure with suture of orifices that can be occasionally found. was considered an absolute contraindication to lung transplant. Nowadays, the International Society of Heart and Lung Transplantation still consider talc poudrage as a very high surgical and postoperative risk factor.6 All of us who have performed transplant surgery in patients previously treated with talc pleurodesis know the intense pleural reaction against talc, which can be especially problematic when fibrosis affects vascular and mediastinal structures. The use of talc in patients of 30--40 years of age who may require a transplant or any other thoracic surgical intervention in the future should be approached with great caution. In these cases the reconstruction of the diaphragm with a Gore-Tex patch has been effective,7 but it is a very arduous task, expensive and, probably unnecessary, especially when no transdiaphragmatic orifices or significant diaphragmatic pathology are observed. The end may justify the use of exceptional means in, especially, complex cases, but it never justifies the recommendation of those means as routine treatment. In conclusion, we should always be extremely thorough in the fulfilment of diagnostic criteria and very cautious when we use or recommend therapeutic procedures that are not yet well established or are not free from future complications.

Contrast-Enhanced Ultrasound-Guided Thoracic Interventions

PurposeUltrasound contrast-enhancing agents have gained an important role in abdominal and thoracic ultrasound. They refine diagnosis and differential diagnosis. Interventions guided by CEUS have been described in the abdomen, and its significance concerning thoracic interventions shall be shown.Material & MethodsDuring difficult interventions on the thorax, i.v. contrast-enhanced ultrasound (CEUS) was performed in addition to conventional B-mode and colour Doppler ultrasound. If indicated, chest tubes were placed. A single drop of SonoVue® was added to 0.9% saline solution and instilled via the drainage catheter. The sonographic findings were documented.ResultsIn difficult interventions on the thorax, the i.v. application of contrast agents is of great benefit. The application of contrast agents via a chest tube reliably shows its localisation, especially its malposition. Insufficient drainage therapy, i.e. in loculated effusions, can be proven.ConclusionApplication of diluted ultrasound contrast agent via drainage catheters significantly facilitates difficult interventions on the thorax and provides considerable additional information. PurposeUltrasound contrast-enhancing agents have gained an important role in abdominal and thoracic ultrasound. They refine diagnosis and differential diagnosis. Interventions guided by CEUS have been described in the abdomen, and its significance concerning thoracic interventions shall be shown. Ultrasound contrast-enhancing agents have gained an important role in abdominal and thoracic ultrasound. They refine diagnosis and differential diagnosis. Interventions guided by CEUS have been described in the abdomen, and its significance concerning thoracic interventions shall be shown. Material & MethodsDuring difficult interventions on the thorax, i.v. contrast-enhanced ultrasound (CEUS) was performed in addition to conventional B-mode and colour Doppler ultrasound. If indicated, chest tubes were placed. A single drop of SonoVue® was added to 0.9% saline solution and instilled via the drainage catheter. The sonographic findings were documented. During difficult interventions on the thorax, i.v. contrast-enhanced ultrasound (CEUS) was performed in addition to conventional B-mode and colour Doppler ultrasound. If indicated, chest tubes were placed. A single drop of SonoVue® was added to 0.9% saline solution and instilled via the drainage catheter. The sonographic findings were documented. ResultsIn difficult interventions on the thorax, the i.v. application of contrast agents is of great benefit. The application of contrast agents via a chest tube reliably shows its localisation, especially its malposition. Insufficient drainage therapy, i.e. in loculated effusions, can be proven. In difficult interventions on the thorax, the i.v. application of contrast agents is of great benefit. The application of contrast agents via a chest tube reliably shows its localisation, especially its malposition. Insufficient drainage therapy, i.e. in loculated effusions, can be proven. ConclusionApplication of diluted ultrasound contrast agent via drainage catheters significantly facilitates difficult interventions on the thorax and provides considerable additional information. Application of diluted ultrasound contrast agent via drainage catheters significantly facilitates difficult interventions on the thorax and provides considerable additional information.

Thoracoscopic Enucleation of a Gastrointestinal Stromal Tumor of the Esophagus

Since the introduction of thoracoscopy in surgery, many thoracic interventions have been considered feasible and safe via the thoracoscopic route. We report the case of a 42-year-old man with a 7.5-cm esophageal gastrointestinal stromal tumor. Thoracoscopic enucleation of the tumor was performed and the patient was discharged on the third postoperative day after tolerating a full oral diet. Given the well-known advantages of minimally invasive surgery, we believe that removal of esophageal submucosal tumors can be attempted using a thoracoscopic approach, even if the tumor is large.

Interventional ultrasonography of the chest: Techniques and indications

Thoracic ultrasonography can be used for diagnostic purposes as well as a guide for diagnostic and therapeutic interventions. When the lesion or fluid collection has been located and the patient properly positioned, the angle of the needle is identified with respect to the transducer. The insertion tract should transgress the smallest possible area of aerated parenchyma. The needle can be introduced with a free-hand technique or with the aid of a needle guide. Correct planning of the procedure reduces intervention time and decreases the risk of complications. The main indications are superficial masses that require biopsy, pleural and parenchymal lesions formerly biopsied with CT or fluoroscopic guidance, and fluid collections that need to be drained. Ultrasound, thanks to its widespread use, simple execution, and low costs, represents a safe, manageable guide for thoracic interventions.

The Incidence of Spinal Cord Ischaemia Following Thoracic and Thoracoabdominal Aortic Endovascular Intervention

The Incidence of Spinal Cord Ischaemia Following Thoracic and Thoracoabdominal Aortic Endovascular Intervention

Feasibility of the transtracheal approach for the thoracic cavity in a large animal model

The aim of this study was to evaluate the performance of a novel transtracheal endoscopic technique for thoracic evaluation and intervention in a large animal model. In 12 animals (6 pigs and 6 dogs) under general anesthesia, a tracheal incision was made on the right lateral wall of the lower trachea and used as an entrance for thoracic evaluation and intervention. Postoperative follow-up included endoscopy at 1 and 2weeks after surgery and necropsy at 2weeks after surgery. Transtracheal opening and thoracic exploration were achieved in all animals. Four animals (3 pigs and 1 dog) died as a result of complications from the procedure. At the follow-up endoscopy, healing at the tracheal opening region was noted in seven animals. The transtracheal approach to the thoracic cavity is technically feasible in both porcine and canine models (4/12 animals died). The canine model is perhaps more suitable than the porcine model for the study of the transtracheal approach to the thoracic cavity.

Thoracoscopic approach in the treatment of breast cancer relapse in the internal mammary lymph node

Regional recurrence of breast cancer may involve the surgical site of mastectomy, axillary lymph nodes and the internal mammary lymphatic chain. Treatment of regional recurrent mammary cancer rarely requires thoracic surgery intervention, except in some selected cases of recurrence in the chest wall. Concerning lymphatic recurrence in breast cancer, the therapeutic choice rarely includes surgical lymph node excision. Exclusive videothoracoscopic (VTS) resection of recurrence in internal mammary lymph nodes has not as yet been reported in the literature. Due to the rare surgical exploration of this lymphatic chain, the thoracoscopic approach is described only in three published studies involving humans, furthermore, in these three descriptions, the operation was performed only for mere staging but not for the whole resection of the recurrent lymphatic structure. We present a case of recurrence of breast cancer in lymph nodes of the internal mammary chain that was treated with complete resection by pure VTS surgery.

Cervical incision thoracic endoscopic surgery: a minimally invasive endoscopic approach in thoracic surgery

Cervical incision thoracic surgery has recently been described. Currently, there is a move to increase the role of flexible endoscopy in surgery. The use of a flexible endoscope through a natural orifice into the thoracic cavity still remains ethically doubtful. The authors present a surgical experimental study using a flexible endoscope through a cervical incision for the exploration of both the mediastinum and the thoracic cavity in a cadaver. An experimental work on 10 refrigerated and non-embalmed cadavers was initiated. We used a unique device - a standard double-channel flexible video gastroscope. Through a small cervical incision, we performed simultaneous exploration of the mediastinum and both pleural cavities. Identification and biopsies of mediastinal lymph nodes at levels 2R, 4R, 7 and 4L were easy to perform in all subjects. In eight cadavers, we performed an assessment of bilateral pleural cavities and multiple pleural biopsies as well as bilateral thoracic sympathectomy. A chest tube was placed in the thoracic cavity at the end of all pleural procedures. The potential advantages of this approach are simultaneous exploration of the mediastinum and pleura and the performance of several thoracic interventions through a small cervical incision. The flexible endoscope could become a surgical tool for thoracic surgery.