Thoracic Surgical Practice Research Articles

Exploring strategies to prevent post-lobectomy space: transient diaphragmatic paralysis using Botulinum Toxin Type A (BTX-A)

ObjectiveVarious techniques to reduce air space after pulmonary lobectomy especially for lung cancer have been an important concern in thoracic surgical practice. The aim of this study was to assess the effectiveness of Botulinum toxin A (BTX-A) injection into the diaphragm to reduce air space after right lower pulmonary lobectomy in an animal model.MethodsTwelve male New Zealand rabbits were randomly allocated into two groups. All animals underwent right lower lobectomy. Then, normal saline of 0,1 ml and 10 units of 0,1 ml Botulinum toxin type A were injected into the muscular part of the right hemidiaphragm in control (n = 6) and BTX-A groups (n = 6) respectively. Residual air space and diaphragmatic elevation were evaluated with chest X-ray pre- and postoperatively. Diaphragmatic elevation was measured as a distance in millimetre from the line connecting the 10th ribs to the midpoint of the right hemidiaphragm.ResultsThe mean diaphragmatic elevation in BTX-A and control groups were 7.0 ± 2.5 and 1.3 ± 1.2 millimetres respectively. Diaphragmatic elevations were significantly higher in BTX-A group (p = 0.0035).ConclusionIntraoperative Botulinum toxin type A injection may reduce postlobectomy spaces effectively via hemidiaphragmatic paralysis in rabbits. Further studies are needed to validate the safe use of Botulinum toxin type A in human beings.

The benefits of a Methcillin Resistant Staphylococcus Aureus (MRSA) prevention policy on thoracic surgical practice

The benefits of a Methcillin Resistant Staphylococcus Aureus (MRSA) prevention policy on thoracic surgical practice

Invited commentary

Invited commentary

Horner's syndrome as a complication in thoracic surgical practice.

To determine the incidence, reasons and prognosis about Horner's syndrome in thoracic surgical patients. In this prospective clinical study, 933 adult patients were assessed between the years of 1998 and 2002. All patients who underwent chest tube insertion (n: 662 patients) or thoracotomy (n: 342 patients), or who had thoracic trauma (n: 268 patients) were routinely examined to detect of Horner's syndrome. The patients with Horner's syndrome due to the invasion of malignant tumour to sympathetic chain were not included in the study. Horner's syndrome was detected in twelve patients from these 933 patients (1.3%). The considered etiologic factors were chest tube pressure in five patients, operative complication in two patients and trauma in five patients. In patients with chest tube pressure were fully recovered from Horner's syndrome but the remaining did not. Malposition of the chest tube is an important aetiological factor of Horner's syndrome, and it is reversible if the tube position is corrected urgently.

Thoracoscopic ipsilateral approach to contralateral bullous lesion in patients with bilateral spontaneous pneumothorax

Background Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgical practice. This study describes a novel ipsilateral approach to a contralateral bullous lesion using VATS to achieve simultaneous bilateral bleb excision and pleurodesis. Methods From 2001 to 2003, 6 patients underwent our ipsilateral approach with VATS for bilateral pneumothorax. The clinical features, surgical indications, and patient outcomes were reviewed. Results All the patients were men between 18 and 35 years old (mean age, 25.8 years). The ipsilateral-approach VATS procedure for bilateral pneumothorax was performed successfully in 4 patients. Two patients were switched to a one-stage sequential bilateral VATS procedure. The bullous lesions were at the apex or confined to the upper lobe in 5 patients; multiple lobes were involved in 1 patient. The bullae were resected with an Endo-GIA stapler or ligated with a homemade endoloop. The mean duration of operation was 54.8 minutes. The mean time of chest tube removal was 4.7 days after insertion, and the mean postoperative stay was 5.7 days. There was no recurrence of pneumothorax during the follow-up period. Conclusions The thoracoscopic ipsilateral approach is technically feasible for treating patients with bilateral pneumothorax.

Place of video-thoracoscopy in thoracic surgical practice.

The advent of video-endoscopy revolutionizes the practice of surgery. Within a short span of time, video-assisted thoracic surgery (VATS) has become an acceptable approach to a wide range of thoracic procedures. The use of VATS as a diagnostic modality is now well established. For therapeutic procedures, VATS has also been generally accepted for the treatment of such conditions as primary spontaneous pneumothorax, loculated effusions, thoracodorsal sympathectomy, and resection of simple mediastinal cysts. Its roles in more complex procedures such as thymectomy and anatemic lung resections, however, remain poorly defined at present, even though the existing intermediate-term results are encouraging. VATS is still in evolution. Miniaturization of instruments promises to reduce access-induced trauma even further. On the other hand, attention to cost-containment is essential if VATS is to be applicable to patients in developing countries. Technology will continue to change. Carefully conducted clinical trials should precede the general acceptance of any new technology, no matter how attractive it may appear initially.

Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†

Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†

Is general thoracic surgical practice evidence based?

Background. In evidence-based medicine clinical decisions are based on experimental evidence of treatment efficacy. There are no data on the extent to which general thoracic surgical practice is evidence based. Methods. A list of 50 thoracic surgical treatments was derived from the operating room log of one surgeon practicing at both a tertiary care cancer center and an affiliated community general hospital. Minor diagnostic procedures and procedures performed as part of experimental protocols were excluded. For each treatment a Medline search was done to obtain the best published evidence supporting the treatment’s efficacy. The evidence was then placed in one of three categories developed by the Oxford Centre for Evidence-Based Medicine: (1) evidence from randomized controlled trials (RCTs); (2) convincing non-experimental evidence; and (3) interventions without substantial evidence. Results. Category 1 evidence supported 7 of 50 thoracic surgical treatments. Category 2 evidence supported 32 treatments, and 11 treatments were without substantial supportive evidence. Conclusions. The majority of commonly performed general thoracic surgical procedures are supported by nonexperimental evidence. Although there are many obstacles to the performance of surgical randomized controlled trials, the limitations of nonrandomized studies are such that continued emphasis on randomized controlled trials in general thoracic surgery is warranted. This study could serve as a baseline reference for future assessments of evidence-based medicine in general thoracic surgical practice.

Video-Assisted Thoracic Surgery-New Directions

Surgical techniques involving the endoscopic evaluation and treatment of diseases of the chest have progressed from their origins in the early 1900s to the modern era of video-assisted, minimally invasive thoracic surgery. As the surgical techniques and instrumentation evolve, the role of video-assisted surgery in a modern general thoracic surgical practice continues to be debated and to change accordingly. This review describes the current role of video-assisted thoracic surgery (VATS) in the management of diseases of the lung (bronchogenic carcinoma, emphysema, and interstitial disease), pleura (pleural effusions and empyema), and mediastinum (tumors and cysts, autonomic dysfunction, and pericardial disease).

Outpatient Chest Tube Management

Patients with indwelling chest tubes inserted for the purpose of evacuating pleural air traditionally are treated in the hospital. The current emphasis on cost-effective medical care and a recent report describing the early discharge of patients who had undergone lung volume reduction operations and had a persistent air leak prompted us to review our overall experience with outpatient tubes in a general thoracic surgical practice. We reviewed the records of patients who had been discharged from the hospital with chest tubes and Heimlich valves in place for venting pleural air over the past 7 years. Ambulatory tube management was used on a total of 240 occasions in three diagnostic groups: pneumothorax (176 cases), prolonged postresection air leak (45 cases), and outpatient thoracoscopic pulmonary wedge excision (19 cases). Failure was defined as hospital admission for complications of tube insertion or function. There were 10 failures in the entire group (4.2%), 4.5% for pneumothorax, 2% for postresection air leak, and 5.3% for outpatient thoracoscopy. There were no deaths or instances of life-threatening problems. The cost of at least 1,263 inpatient hospital days was saved. The presence of a chest tube, with or without an air leak, does not always require hospitalization. Admission can be avoided in most patients with primary spontaneous pneumothorax and in selected patients with pneumothorax of other causes. The postoperative hospital stay can be shortened for many patients who have a prolonged air leak after pulmonary resection. Ambulatory tube management also makes feasible outpatient thoracoscopy for noneffusive processes.

Role of Computed Tomography and Mediastinoscopy in the Staging of Lung Cancer: A Canadian Opinion Poll

OBJECTIVES: To address the Canadian Lung Oncology group’s recently published results and recommendations suggesting that mediastinoscopy is unnecessary in the staging nonsmall cell lung cancer when computed tomography shows no enlarged mediastinal lymph nodes (larger than 1 cm in short axis); to evaluate the practice of thoracic surgeons across Canada in staging presumably operable lung cancer; and to assess the effect of the Canadian Lung Oncology Group’s recommendations on current thoracic surgical practice in Canada.DESIGN: A survey of Canadian thoracic surgeons (n=38) regarding the roles of computed tomography and mediastinoscopy in evaluating mediastinal disease in patients with operable lung cancer.RESULTS: There was an 89% response rate. Ninety-one per cent of surgeons used computed tomography routinely, but only 10% of surgeons thought it to be more accurate than mediastinoscopy. Sixty-eight per cent would rely on a negative scan (nodes smaller than 1 cm in shortest diameter) to rule out mediastinal disease.CONCLUSIONS: There are numerous circumstances where negative computed tomography does not adequately assess nodal status. A guideline for the use of computed tomography and mediastinoscopy in evaluating and staging lung cancer is presented. Mediastinoscopy should be considered in the staging of patients with negative computed tomography if the patient is at high risk of mediastinal disease, where negative computed tomography is typically unreliable and when the risk associated with an unnecessary thoracotomy is high.

Video-Assisted Thoracic Surgery Current State of the Art

The author reviews the current state of the art of video-assisted thoracic surgery in the context of modern thoracic surgical practice. Thoracoscopy has been a part of thoracic surgical practice for many years, but was used mainly for diagnosis of pleural disease. The development of laparoscopic cholecystectomy awakened a new interest in this technique and led to the development of many new therapeutic and diagnostic applications of video-assisted thoracic surgery. Current literature and the author's personal experience with more than 500 cases are reviewed. Video-assisted techniques have proven useful for the performance of a broad spectrum of thoracic surgical procedures. Patients may experience less pain and have a shorter hospital stay after a video-assisted procedure. Definitive proof of less morbidity when compared with the analagous open procedure remains to be determined. Patient acceptance has been high, and most thoracic surgeons use these techniques in their practice. Video-assisted thoracic surgical procedures have made a significant impact on the practice of thoracic surgery. Advantages and disadvantages of specific procedures remain to be definitively determined. Surgeons have learned these techniques and have kept morbidity to acceptance levels during the learning phase. Where these techniques ultimately fit into the overall practice remains to be determined as more experience is gained.

Complications of thoracoscopy

Although thoracoscopy has been a part of thoracic surgical practice for many years, the advent of video-assisted techniques has greatly expanded the indications and the uses of this procedure. Where previously thoracoscopy was performed mainly for diagnostic purposes, it now has assumed, a major role in the therapy of chest pathology. In an attempt to inject a modicum of perspective into the tremendous enthusiasm that has accompanied the meteoric rise of video-assisted thoracoscopy, we have reviewed the experience at the Hospital of the University of Pennsylvania accumulated over the 1-year period from December 1991 to December 1992, specifically looking at complications resulting from the thoracoscopic procedure. During this period we performed 266 thoracoscopic procedures with no deaths. The overall incidence of complications was 10%, with the most prevalent complication being prolonged air leak (3.7%). There were five superficial wound infections (1.9%) and 5 patients who bled significantly enough to require either transfusion or reoperation, or both. In 11 patients (4.1%), the proposed thoracoscopic procedure could not be completed as planned, and a thoracotomy was required. The incidence of complications is certainly acceptable and similar to that seen after thoracotomy, although overall hospital stay is shorter and patients seem to have less pain and return to normal activity sooner. One would expect the incidence of complications to further decrease as surgeons acquire more experience with this significant modification and improvement of an old technique.

The Changing Pattern of Thoracic Surgery in the United Kingdom 1963–1982

During the period 1963-1982 a total of 11,459 patients with general surgical and thoracic conditions were admitted to the Churchill and John Radcliffe Hospitals in Oxford under the care of a single thoracic surgeon. 55.1% of the admissions were for general surgical conditions whereas 44.9% were for a thoracic disorder. The total period has been studied by dividing it into three subgroups of 7, 6 and 7 years (1963-1969, 1970-1975, 1976-1982). The percentage of thoracic patients treated during the three periods was found to be 48.86%, 41.73% and 50.11% respectively. The three periods studied have been subdivided into major disease groups and the changes in these groups have been studied in detail. During this 20-year period there has been a dramatic change in the makeup of a typical thoracic surgical practice. This is in part due to the changing pattern and prevalence of many of the diseases treated by thoracic surgeons, but is also due to a change in referral patterns, the distribution of patients between thoracic and general surgeons and also the dichotomy emerging between thoracic and cardiac surgeons.

The Left Thoracoabdominal Incision

The left thoracoabdominal incision is approaching its first century of use. Its history is reviewed. The incision provides wide exposure of the spleen, stomach, left hemidiaphragm, aorta, and esophagus; exposure is not limited to the distal esophagus. Because of the superb exposure it offers, its wide clinical application, and its overall safety, the thoracoabdominal incision should continue to be a viable surgical option in current thoracic surgical practice.

Thoracic and cardiovascular operations in the United States, 1979 to 1984

Using data from the National Center for Health Statistics, I conducted an in-depth analysis of numbers of thoracic and cardiovascular operations from 1979 to 1984. This is the first full 5 year period since the inception of International Classification of Diseases, Ninth Revision, Clinical Modification codes, and the findings delineate the present status of thoracic and cardiovascular surgery in the United States. During the study period there was a 34% increase in total numbers of thoracic and cardiovascular operations. Since 1970 there has been a total increase in numbers of thoracic and cardiovascular operations of 150%. In 1983 thoracic and cardiovascular surgeons performed 191,000 coronary artery bypasses. This operation is the most common thoracic and cardiovascular procedure and has become the nineteenth most common operation now performed in this country. Pacemaker placement, revision, or removal (190,000) is the second most common thoracic and cardiovascular operation and the country's twentieth. The twenty most common thoracic and cardiovascular operations constitute 87% of all thoracic and cardiovascular operations. In 1983 thoracic and cardiovascular operations represented 3% of all operations completed in this country. These figures represent the dynamics of thoracic and cardiovascular surgical practice. They demonstrate that numbers of thoracic and cardiovascular operations have consistently increased over the past 15 years. However, this increase is almost entirely due to the advent of coronary artery bypass.

Malignant fibrous histiocytoma in thoracic surgical practice

Malignant fibrous histiocytoma is a rare, although increasingly recognized, deep-seated pleomorphic sarcoma. A primitive tumor, it arises from tissue histiocytes and typically occurs in the extremities. Primary intrathoracic tumors have been reported rarely. The presentation of malignant fibrous histiocytoma in our series of seven patients has been varied. Two cases presented as solitary primary intrapulmonary tumors, two as primary chest wall tumors, one as an anterior mediastinal mass, one as a retroperitoneal tumor extending cephalad through the diaphragm, and one as a late metastasis from a primary pelvic site. Malignant fibrous histiocytoma is aggressive, with a propensity for early local and distant spread; three of the patients in our series died of progressive disease within 17 months of operation. The histologic nature of the tumor makes diagnosis on small biopsy specimens difficult and frequently misleading. We would suggest a policy of open biopsy to obtain adequate and representative specimens for histologic study and preoperative computed tomographic scanning to augment the clinical search for metastatic disease and to facilitate planning of subsequent radical, excisional operation. The preoperative use of deep x-ray therapy or the newer chemotherapeutic agents may reduce tumor bulk and thereby facilitate radical operation, which presently appears to be the most appropriate primary modality of treatment of malignant fibrous histiocytoma.