Thoracoscopic Treatment Research Articles

Video-assisted thoracoscopic resection for intralobar pulmonary sequestration

Video-assisted thoracoscopic treatment of intralobar pulmonary sequestration in an obese (120 kg, body mass index 42) young man is described. Two aberrant arteries originating from the descending thoracic aorta were transected with a vascular stapler, and a left lower lobectomy was successfully performed thoracoscopically. Three-dimensional chest computed tomography was used to identify the aberrant vessels. Video-assisted thoracoscopic lobectomy is useful and minimally invasive for treating pulmonary sequestration, especially in obese patients.

Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax

Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise. When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair. The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings. The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon.

Cold coagulation of blebs and bullae in the spontaneous pneumothorax: a new procedure alternative to endostapler resection

Further improvements in the thoracoscopic treatment of spontaneous pneumothorax may reduce the already low invasiveness of the procedure. We have recently experimented with a new device for the coagulation of blebs as an alternative to endostapler resection. Patients with recurrent or persistent spontaneous pneumothorax underwent thoracoscopic treatment. Those with blebs or small bullae were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. Most operations were performed making only two incisions, in some cases under awake epidural anaesthesia. Results are comparable to those of a series of standard thoracoscopic treatments already reported in the literature.

Long-term clinical results of thoracoscopic Heller's myotomy in the treatment of achalasia☆

The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy (THM). All patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire and oesophageal manometry and/or 24h pH monitoring were undertaken when clinically indicated. Fifty-six consecutive patients (32 males, 24 females, mean age 45+/-18.7 years) suffering from grade 4 dysphagia underwent THM between January 1992 and March 2006. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4+/-10.6 mmHg. Eighteen patients (32.1%) had undergone previous pneumatic dilatations. There were no hospital deaths. Oesophageal perforation occurred in two patients; one repaired thoracoscopically and one at thoracotomy. Mean hospital stay was 4+/-1.37 days. At mean follow-up of 5.9+/-4.66 years, freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n=27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37+/-0.77 vs 4.00+/-0; p<0.001). Seven patients (12.5%) with troublesome residual or recurrent grade 3-4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8+/-6.1-30.0+/-5.4 mmHg (p<0.001). Of these patients, three patients with grade 4 dysphagia were reoperated: one open Heller's myotomy and two by cardia resection. Eleven patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine patients (16.9%) and all were successfully managed with medical therapy. The results of thoracoscopic treatment for achalasia are at least equivalent to historical outcomes obtained with open surgery but the patient is spared major thoracotomy or the acid reflux associated with a laparoscopic approach.

Thoracoscopic Total Parietal Pleurectomy for Primary Spontaneous Pneumothorax

Although the management of spontaneous pneumothorax through a thoracotomy traditionally included apical pleurectomy, thoracoscopic treatment of this problem does not generally include pleurectomy. Thoracoscopy in fact allows excellent exposure to perform total parietal pleurectomy, and we hypothesize that including total pleurectomy will reduce recurrences. We describe here the technique of thoracoscopic total parietal pleurectomy and the early outcomes afterward.

Thoracoscopic Treatment of Barium-induced Lung Entrapment Complicating Esophageal Perforation

Patients with suspected esophageal perforations are routinely evaluated with a swallow study using a water-soluble contrast medium followed by thin-barium administration when the first fails to demonstrate a leak. Intrapleural barium instillation has been historically correlated with mild degree of pleural inflammation and a low-grade talclike reactive process. Still, if administered in excessive quantities, it may contribute to complicate the clinical scenario of pleural contamination secondary to the perforated esophagus. We report the case of a patient that presented with a malignant esophageal perforation and developed a trapped lung from extensive pleural contamination with barium sulfate that required video-assisted thoracic drainage and decortication with successful reexpansion of the lung and resolution of the acute symptoms.

The Use of Thoracoscopy in the Management of Adolescent Idiopathic Scoliosis

Retrospective case cohort series. To analyze the outcomes of thoracoscopy in the surgical treatment of adolescent idiopathic scoliosis. Traditionally, progressive idiopathic scoliosis has been treated surgically with either an open posterior, anterior, or combined surgical approach. Surgical methods are being explored to minimize the extent of soft tissue disruption such as thoracoscopy followed spinal release, bone grafting, and instrumentation. Several authors have reported good results using thoracoscopy in the treatment of spinal deformity following a requisite learning curve. A consecutive case cohort series of 45 adolescent patients with idiopathic scoliosis evaluated and treated at a single institution. Patients with a progressive deformity underwent a thoracoscopically assisted curve correction, fusion, and instrumentation procedure. After surgery, patients were assessed at 1, 3, 6, and 12 months and then annually. All patients underwent successful thoracoscopic instrumentation and fusion without the need for an open conversion. The average preoperative thoracolumbar Cobb measurement of the major curve was 51.6 degrees . The thoracolumbar levels instrumented anteriorly ranged from T7 to L3 and had an average postoperative Cobb angle of 6.58 degrees , with an overall improvement of 87.3%. To date, at a mean follow up of 4.6 years, all curves have maintained correction. Sagittal balance was recreated or maintained through the application of interbody femoral ring allografts. Operative times averaged 5 hours and 46 minutes, with a range of 3 hours, 48 minutes to 6 hours, 55 minutes. Hospital stays averaged 2.9 days, with a range of 2 to 7 days. All patients were completely off pain medication before their first postoperative visit at 4 weeks. Children were back to school between 2 and 4 weeks on average. There were a total of 3 complications. One patient experienced transient chest wall numbness, which resolved by 3 months. Two patients developed postoperative mucus plugging in the ventilated lung. Endoscopic thoracoscopic spinal deformity correction, fusion, and instrumentation is a safe and feasible method of surgical management of an adolescent patient with progressive scoliosis. The key to successful fusion is a total discectomy and complete endplate removal. This method appears to be comparable to open procedures in terms of curve correction with significantly shorter hospitalization and rehabilitation due to less surgical discomfort. The thoracoscopic correction of adolescent scoliosis warrants continued development and evaluation as a surgical method of scoliosis correction.

Thoracoscopic treatment of esophageal atresia with distal fistula and of tracheomalacia

Single center experience with thoracoscopic repair of esophageal atresia with distal fistula and of tracheomalacia. Between May 2000 and December 2006, 51 neonates with an esophageal atresia were presented for thoracoscopic repair. Gestational age varied from 31 3/7 to 42 2/7 weeks (M = 37 2/7). Birth weight was between 1025 g and 4030 g (mean 2620 g). Concomitant anomalies or VACTERL association were encoutered in 31 patients (61%). Duration of the operation was from 90 minutes to 390 minutes (mean 178 minutes). All but 1 patient had an esophageal atresia with a distal fistula. Six patients had tracheomalacia requiring aortopexia, which was performed thoracoscopically. In 2 patients the thoracoscopic procedure had to be converted to a thoracotomy. All other patients underwent a successful thoracoscopic repair. One patient died in the postoperative period because of sepsis. A total of 22 patients (45%) developed a stenosis in the postoperative follow up (1 month-7y 7 month) requiring 1 to 18 dilatations (mean 1.5). Postoperative leakage occurred in 9 patients (18%). Recurrent fistula was encountered in 2 patients. A total of 11 patients (22%) underwent a laparoscopic antireflux procedure for either recurring stenosis (8) or ALTES (3). Six children (12%) underwent thoracoscopic aortopexy for tracheomalacia. In 2 children symptoms recurred for which a successful repeat thoracoscopic aortopexy was undertaken. The thoracoscopic approach to the treatment of esophageal atresia and tracheomalacia is becoming increasingly accepted. The cosmesis is undoubtedly better. The secundary effects like thoracic cage deformities, winged scapula, or scoliosis have not yet been described and are expected to be reduced in comparison to the open technique. Sequelae like leakage, stenosis, recurrent fistulae, and GERD and ALTES will probably remain the same. Whether thoracoscopic dissection has less detrimental effect on disturbed motility remains to be proven. Thoracoscopic aortopexy for severely symptomatic tracheomalacia is relatively simple. Even repeat thoracoscopic aortopexy is not that difficult. It was immediately effective in 2/3 of the patients.

Mini-Thoracotomy or Thoracoscopic Treatment for Medially Located Thoracic Herniated Disc?

A retrospective cohort study. Comparison of the mini-thoracotomy (mini-TTA) and thoracoscopy for the treatment of calcified thoracic herniated disc. Thoracoscopy has been popularized at the cost of the traditional thoracotomy for the treatment of calcified herniated discs. However, the learning curve is steep. Given the low incidence of herniated thoracic discs, it will be difficult for a group of spinal surgeons to gain experience. Newer, minimally invasive techniques with a nearly absent learning curve are evolving. One of these techniques is the mini-TTA. Retrospectively, the charts of patients that underwent a mini-TTA or thoracoscopy were retrieved. Seven patients underwent a thoracoscopy, and 21 a mini-TTA. Although the groups are limited, a statistical significant difference in gender, age, duration of surgery, duration of the necessity of a chest drain, intraoperative blood loss, or duration of the postoperative stay on the intensive care unit was not reached. At the last follow-up in the thoracoscopic group, 2 patients had some neuropathic thoracic incisional pain. In all patients, a complete removal of the calcified disc was ascertained with a postoperative computed tomography scan. The mini-TTA has some theoretical advantages over a thoracoscopy. It is also a minimally invasive approach. The thoracoscopy has a steep learning curve, whereas the mini-TTA is simple to apply. Classic microsurgical bimanual techniques can be used.

Successful thoracoscopic treatment of severe bilateral empyema in an infant

We report a case of rapid progression of bilateral pyothorax exacerbated by viral influenza in an infant. The patient, an 11-month-old girl, was diagnosed with viral influenza, and oseltamivir phosphate was administered. However, after only 4 days the influenza was followed by rapid progression of methicillin-susceptible Staphylococcus aureus (MSSA) pneumonia and pyothorax, resulting in disseminated intravascular coagulation. Because thoracentesis and antibiotics could not control the pyothorax, a serious condition, we performed bilateral video-assisted thoracoscopic decortication on the eighth hospital day. She recovered with excellent lung expansion and was discharged on the 37th hospital day.

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

Purpose The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision. Methods From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization. Results The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated ( P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia. Conclusion The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Thoracoscopic treatment of pulmonary sequestration☆

Pulmonary sequestration is a rare congenital malformation and may be the cause of recurrent infections or hemoptysis. It has been shown in case reports that resection by video-assisted thoracic surgery (VATS) is feasible despite the possible technical difficulties due to inflammatory changes, but its role has not been evaluated yet in a larger series of consecutively treated patients. Retrospective analysis of all consecutively thoracoscopically treated patients (between January 1991 and January 2005) with pulmonary sequestration in a single center. We included 14 patients in the study who fulfilled the criteria; seven were women. Median age was 33 years (20-64 years). The following data were analyzed for all patients: major symptoms, diagnostic procedures, treatment, and outcome. Operative parameters and findings including operating time, blood loss, anatomical location of the sequestration, and feeding vessels were evaluated. Leading symptoms were recurrent infections (10), hemoptysis (3), and chest discomfort (1). The diagnosis was made by CT scan. Additionally, an arteriography or an angio-MRI was done in three patients and one patient, respectively. Thirteen intralobar (all lower lobes, eight on the right) and one left-sided extralobar pulmonary sequestration were resected. We performed eight lobectomies, four atypical segmentectomies, one extralobar resection, and one occlusion of the aberrant artery. One case had to be converted to a thoracotomy due to bleeding from the aberrant artery. There was no mortality. Complications included pneumonia in three cases, one hemothorax, one pneumothorax after removing the chest tube, and one wound infection. All were treated conservatively. Thoracoscopic treatment of pulmonary sequestration is feasible in experienced hands. The aberrant systemic artery can be freed and dissected safely despite the frequently occurring inflammatory changes. Conversion rate to thoracotomy is low.

A new minimally invasive heart surgery instrument for atrial fibrillation treatment: firstin vitro and animal tests

The paper presents a new robotic system for beating heart surgery. The final goal of this project is to develop a tele-operated system for the thoracoscopic treatment of patients with atrial fibrillation. The system consists of a robot that moves an innovative end-effector used to perform lines as in the Cox-Maze technique. The device is an electrode mesh that is introduced in the thorax through a trocar and is deployed inside the left atrium, where it can create selective ablation lines at any atrial region, using radio frequency. The current version of the umbrella has 22 electrodes. Using visual feedback from an ultrasound based navigation system, the surgeon can choose which electrodes on the mesh to activate. Once the umbrella is in contact with the endocardium of the left atrium, at the expected position, the surgeon activates the chosen electrodes sequentially. The umbrella can then be moved to another position. In vitro and in vivo animal tests have been carried out in order to test and improve the instrument, the robotic system and the operative procedure. The performed trials proved the ability of the system to treat atrial fibrillation. More in vivo tests are currently being performed to make the robot and its device ready for clinical use.

Video-assisted thoracoscopic surgery and open decortication for pleural empyema

Video-assisted thoracoscopic treatment is an elegant method for the treatment of ATS stage II fibrinopurulent empyema. It has been shown to be superior to repeat instillation of fibrinolytic agents into the chest cavity. However, a more chronic empyema (organizing empyema, ATS stage III empyema) requires open decortication in order to prevent ongoing infection and late restriction. Conversion thoracotomy should be liberally used if a chronic stage III empyema is found at VATS exploration since open decortication is still the best treatment modality for chronic empyema.

Additional Minocycline Pleurodesis after Thoracoscopic Surgery for Primary Spontaneous Pneumothorax

Ipsilateral recurrence rates of spontaneous pneumothorax after video-assisted thoracoscopic surgery are higher than rates after open thoracotomy. This study was conducted to determine whether additional minocycline pleurodesis would be effective in diminishing recurrence after video-assisted thoracoscopic surgery treatment of primary spontaneous pneumothorax. Between June 2001 and February 2004, 202 patients with primary spontaneous pneumothorax were treated by conventional or needlescopic video-assisted thoracoscopic surgery. The procedures included resection of blebs and mechanical pleurodesis by scrubbing the parietal pleura. After the operation, patients were randomly assigned to additional minocycline pleurodesis (103 patients) or to observation (99 patients). Patients in the minocycline group had higher intensity chest pain and required a higher accumulated dose of meperidine. Short-term results showed that the two groups had comparable chest drainage duration, postoperative hospital stay, and complication rates. Patients in the minocycline group demonstrated a trend of decreased rate of prolonged air leaks (1.9 vs. 6.1%, p = 0.100). After a mean follow-up of 29 mo (12-47 mo), recurrent ipsilateral pneumothorax was noted in two patients in the minocycline group and eight patients in the observation group (p = 0.044 by the Kaplan-Meier method and log-rank test). Postoperative long-term residual chest pain and pulmonary function were comparable in both groups. Although associated with intense immediate chest pain, additional minocycline pleurodesis is a safe and convenient procedure that can reduce the rate of ipsilateral recurrence after thoracoscopic treatment for primary spontaneous pneumothorax.

Thoracoscopic treatment of pulmonary hydatid cyst in a child

Hydatid disease has a wide geographic distribution around the world. In human, the lungs are the second most commonly affected sites. Pulmonary hydatidosis is much more frequently encountered in children than in adults. Surgical treatment has remained the standard option in the management of hydatid disease. However, surgeons were able to replicate the principles of conventional surgery using minimally invasive techniques. Herein, we report a case of pulmonary hydatid cyst in a 9-year-old girl treated successfully using the thoracoscopic approach.

Thoracoscopy in treatment of bullous lung disease complicated by pneumothorax

The authors’ treatment experience of 292 patients with spontaneous pneumothorax is presented. Results of the pleural drainage (188 patients), thoracoscopy and talc pleurodesis (43 patients), videothoracoscopic surgical treatment (61 patients) are discussed. Recurrent pneumothorax after videothoracoscopic treatment was in 1 case only and only 1 patient needed in open thoracotomy (p &lt; 0.05). Videothoracoscopy is an accurate, safe, and reliable alternative for open thoracotomy and conservative treatment in the management of patients with spontaneous pneumothorax.

Thoracoscopic repair of H-type tracheoesophageal fistula in the newborn: A technical case report

H-type tracheoesophageal fistula (H-TEF) without esophageal atresia makes up 4% to 5% of esophageal congenital abnormalities. The authors present the thoracoscopic treatment of a 2.47-kg newborn boy with a fistula between the second and third thoracic vertebrae diagnosed by esophagography. Four trocars were used for fistula closure, and tracheal and esophageal suturing were accomplished without intraoperative incident. Five days after surgery, results of a barium swallow excluded anastomotic leaks. The chest tube was removed, and oral feeding was initiated.

Thoracoscopic Treatment of Bronchiectasis Secondary to Resistant Organisms

Thoracoscopic Treatment of Bronchiectasis Secondary to Resistant Organisms

Single port thoracoscopy for the treatment of pleural empyema in children

Background/purpose This report is an evaluation of a single-port technique for the thoracoscopic treatment of pleural empyema in children. Methods Ten consecutive patients with pleural empyema were treated by means of a “Single Port Thoracoscopy” (SPOT). Mean age was 6.9 years (range, 2 to 13 years). The surgery was performed 5 to 26 days after the onset of symptoms. Three patients received this treatment as the first procedure, whereas the other 7 underwent closed placement of a chest tube, 3 to 12 days before the surgery. Only 1 11.5-mm thoracoport was used. Through this single port, standard scopes and instruments were introduced simultaneously to debride and unify the pleural space. Results Satisfactory debridement of the pleural cavity was achieved in all cases. Mean operating time was 70 minutes (range, 60 to 140). There were no intraoperative complications. The chest tube was removed 2 to 5 days after the surgery. Eight patients remained afebrile from the day of the surgery, and 2 had mild fever that disappeared 36 hours after the surgery. Mean hospital stay after SPOT was 4 days (range, 3 to 7). Conclusions SPOT is a safe and effective proceeding for the treatment of pleural empyema in children with the advantage of better cosmetic results than the multiport techniques.