Use Of Video-assisted Thoracoscopic Surgery Research Articles

Video-assisted thoracoscopic surgery for patients with pulmonary coccidioidomycosis

The study objective was to evaluate the use of video-assisted thoracoscopic surgery for removal of pulmonary sequelae of the fungal infection coccidioidomycosis. Retrospective chart review of all patients with pulmonary coccidioidomycosis treated surgically at our tertiary care center between January 1, 2009, and August 31, 2012. Of 2166 patients treated for pulmonary coccidioidomycosis, 58 (2.7%) (median age, 52 years [range, 18-84 years]) required surgical treatment. Surgical resection was performed for diagnosis (n=28 [48%]); 17 with positive positron emission tomography findings); persistent or progressive symptoms despite antifungal therapy (n=23 [40%]); or complications (n=7 [12%] of cavity rupture/infection). Of 33 patients (57%) who had serology performed, 23 (70%) had positive results. Video-assisted thoracoscopic surgery was used for most (95%; n=55) procedures, including 38 (67%) wedge resections, 14 (24%) segmentectomies, and 6 (11%) lobectomies; 4 patients also required additional decortication. Major (8%), including 1 death, and minor (12%) complications occurred in 12 patients postoperatively. Median hospitalization was 3 days (range, 1-8 days). Postoperative antifungal therapy was administered to 50% of patients for a median duration of 2 months. No patient had recurrent coccidioidomycosis at a median follow-up of 19 months. Although rarely necessary for pulmonary coccidioidomycosis, surgical intervention may be indicated. Specific indications include refractory symptomatic disease and complications of the infection, such as cavity rupture. Excisional biopsies also may be required for diagnostic confirmation of indeterminate pulmonary nodules. With video-assisted thoracoscopic surgery, diagnostic and therapeutic intervention can be undertaken with a low risk of complications and shorter length of hospital stay.

Minimally Invasive Resection for Mediastinal Ectopic Parathyroid Glands

We reviewed our experience with ectopic mediastinal parathyroidectomy. Between March 1980 and September 2010,mediastinal parathyroidectomy was performed in33 patients with hypercalcemia secondary to hyperparathyroidism. Primary hyperparathyroidism was the main diagnosis in 32 patients (97%). Technetium-sestamibi scan was used in 23 (70%) for preoperative localization. Minimally invasive resections were performed in 18 patients (55%), and 15 (45%) underwent open surgery. The most common minimally invasive surgery approach was video-assisted thoracoscopy in 9 patients (27%); the most common open approach was median sternotomy in 11 (33%). Intraoperative parathyroid hormone monitoring was used in 22 patients (67%). The ectopic glands were intrathymic in 15 patients (45%), in the aortopulmonary window in 7 (21%), and in other intrathoracic locations in the remaining 11 (33%). Parathyroid adenomas were identified in 21 patients (64%); parathyroid hyperplasia and carcinoma were identified in 9 (27%) and 3 (9%), respectively. No early mortality occurred in either group. Reoperation was required in 1 patient in the minimally invasive surgery group because of hemothorax. Morbidity occurred in 8 patients (24%), the most common of which was hypocalcemia in 4 (12%). The mean length of stay was significantly shorter in the minimally invasive surgery group (2 versus 6 days; p < 0.001) but mortality and morbidity were not statistically different between the two groups (p= 0.05). Mean follow-up was 3 ± 3.7 years. Minimally invasive mediastinal parathyroidectomy has similar outcomes to open surgery, with significantly shorter length of hospital stay.

Applications of video-assisted thoracic surgery for the diagnosis and treatment of patients with small pulmonary nodules

背景与目的随着胸部CT的应用推广，孤立性肺结节的出现逐渐增多，尤其是胸部薄层高分辨CT的检查，检出直径10 mm以下的微小结节的概率增高，临床上对于如何诊治这类微小结节仍存在较大争议。本研究旨在探讨胸腔镜手术在肺部微小结节的诊断和治疗中的价值。方法2009年11月-2012年5月，对64例肺微结节应用电视胸腔镜手术先行肺结节楔形切除，术前均无明确病理诊断，术中送快速冰冻病理检查，根据病理结果 < 综合考虑后决定手术方式。结果原发性肺癌行全胸腔镜肺叶切除+淋巴结清扫20例; 行肺楔形切除44例，其中良性肿瘤21例、癌前病变18例、转移癌3例、不适合肺叶切除的原发性肺癌2例。所有患者均明确病理诊断，确诊率100%。全组患者手术顺利，无严重手术并发症和围手术期死亡。结论肺部微小结节影像学诊断有一定难度; 胸腔镜手术诊治肺部微小结节创伤小、诊断准确，具有重要的诊断意义。术前CT引导的hook-wire定位可帮助手术中探查病变部位。

Introducing Video‐Assisted Thoracoscopy for Trauma into a South African Township Hospital

The use of video-assisted thoracoscopic surgery (VATS) is well established in trauma practice. This modality is readily available to centers with well-equipped operating facilities but may be challenging to introduce into resource-constrained institutions such as many South African township hospitals. We implemented VATS for retained post-traumatic pleural collections in our institution in 2007, and we have now performed an audit of the first 3 years of our experience. A retrospective chart review was conducted of all patients who had undergone VATS from June 2007 to May 2010, and statistical analysis was performed to elucidate the findings. Forty-three patients were examined, 40 of whom (93 %) were male. The mean age was 32 years (range: 15-52 years). Thirty-five patients (81 %) had stab injuries, 6 (14 %) had blunt injuries, and 2 (4 %) had gunshot wounds. Mean time from injury to VATS was 12.4 days (range: 3-31 days). Thirteen patients (30 %) had empyema at the time of VATS. The mean time from VATS to discharge was 9 days (range: 3-30 days). The postoperative complication rate was 14 % and included pneumonia (n = 3) and re-collections (n = 3, two of which were managed by reinsertion of a chest drain, and one cleared without further intervention). Further analysis revealed a longer postoperative length of stay when empyema was present at VATS (8 days for no empyema vs. 11 days when empyema was present; p = 0.027). The incidence of empyema increased progressively the longer the delay between injury and VATS (0 % for VATS performed in week 1, 32 % for VATS in week 2, 50 % for VATS in week 3, and 60 % for VATS beyond week 3; p = 0.019). The incidence of empyema increased when >1 chest drain was inserted prior to VATS (15 % for 0-1 chest drain vs. 43 % for >1 chest drain; p = 0.043). Introducing VATS for retained post-traumatic collections into a relatively resource-constrained township hospital in South Africa is safe and effective. Consideration should be given to performing VATS early and avoiding the use of a second and third chest drain for retained collections. This approach may lead to decreased incidence of empyema and shorter overall hospital stay.

Spontaneous Pneumothorax Recurrence and Surgery.

Spontaneous pneumothorax that occurs in patients with no underlying lung disease is termed primary spontaneous pneumothorax (PSP). Recurrence of pneumothorax is usually seen without surgical procedures at any time. The aim of this study was to determine the recurrence time and rate of PSP after the first episode. A total of 82 PSP patients who had been treated in a thoracic surgery clinic between March 2011 and August 2012 were studied retrospectively. Video-assisted thoracoscopic surgery (VATS) was performed in 14 of 82 patients because of prolonged air leakage. These patients were excluded from the study to determine the recurrence period of PSP in our cases. Simple endotracheal intubation with low-volume high-frequency ventilation and three-port VATS technique were applied. Bullae or blebs were excised using an endoscopic linear stapler. Apical pleurectomy was performed in all of the patients. There were no cases in which VATS was converted to open thoracotomy. Recurrence of PSP was seen in 18 (26.47%) of 68 patients. We found 26.47% recurrence at the first 7months, of which 94.4% occurred at the first 6months. About 77.77% of these recurrences occurred at 3months after discharge from hospital. Recurrence after the first episode of PSP is a common problem within the first 6months. The thoracic surgeon should give knowledge about it to all patients. With the greater use of VATS for thoracic pathologies, it could be performed for the first period of pneumothorax in the future.

Invited Commentary

In this issue of The Annals, Pompeo and colleagues report their outcome in 30 patients with suspected interstitial lung disease (ILD) who underwent awake surgical lung biopsy with the use of video-assisted thoracoscopic surgery (VATS) in a single institution [1]. Twenty such procedures were performed with the patients under thoracic epidural anesthesia and ten with the use of intercostal nerve blocks. The patients were awake and were breathing spontaneously during the whole procedure. Open pneumothorax was then induced to perform the lung biopsy with endostaplers.

Removal of a bullet in the pericardial cavity by video-assisted thoracoscopic surgery

The use of video-assisted thoracoscopic surgery (VATS) in dealing with thoracic trauma has been well established. VATS avoids a thoracotomy and offers excellent visualization of the entire pleural cavity. The removal of bullets from the pleural cavity using VATS has also been reported, but, to our knowledge, this is the first time a bullet has been removed from the pericardial cavity using VATS.

Erdheim–Chester disease: The role of video-assisted thoracoscopic surgery in diagnosing and treating cardiac involvement

INTRODUCTIONErdheim–Chester disease is a rare, non-Langerhans histiocytosis in which pericardial involvement is diagnosed with increasing frequency and is associated with high mortality rates. PRESENTATION OF CASEA 53-year-old woman presented with progressive exertional dyspnea and pericardial effusion was discovered. Further investigations revealed the presence of a diffuse, infiltrating process and a diagnosis of Erdheim–Chester disease was made. An emergent pericardiocentesis by subxiphoid approach was completed but recurrent drainage obviated removal of the pigtail catheter. A pleuro-pericardial window was placed using video-assisted thoracoscopic surgery (VATS) and analysis of the resected specimen confirmed pericardial involvement. DISCUSSIONIn this case, high pericardial fluid output demanded definitive treatment of the pericardial effusion. Traditionally this would be completed via thoracotomy. VATS is a minimally invasive alternative which permits exploration of the thoracic cavity and the creation of a pleuropericardial window. CONCLUSIONWe describe, for the first time, the successful use of VATS for both diagnostic confirmation and therapeutic relief of recurrent pericardial fluid drainage due to pericardial involvement by Erdheim–Chester disease.

Video-Assisted Thoracoscopic Surgery Plus Lumbar Mini-Open Surgery for Adolescent Idiopathic Scoliosis

PurposeThe objectives of this study are to describe the outcome of adolescent idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Surgery (VATS) plus supplementary minimal incision in the lumbar region for thoracic and lumbar deformity correction and fusion.Materials and MethodsThis is a case series of 13 patients treated with VATS plus lumbar mini-open surgery for AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar regions were included in this study: 5 of these patients were classified as Lenke type 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar area to gain access to the lumbar spine via the retroperitoneal space. All patients had a minimum follow-up of 1 year.ResultsThe average number of fused vertebrae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly improved at the final follow-up (p < 0.05).ConclusionIndications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with minimal post-operative scarring.

P67 Outcomes from surgical management of pleural infection: 12-year experience from a tertiary cardiothoracic centre

Introduction and ObjectivesThoracic empyema affects >65 000 patients/year in the US and UK. Up to 50% require surgical drainage, and 15% die. We describe clinical features, microbiology, risk factors and...

Video-assisted Thoracoscopic Surgery (VATS) Drainage of Salmonella enteritidis Empyema and Needle-localization for Retrieval of a Dropped Gallstone

Spillage of gallstones into the peritoneal cavity (dropped gallstones) is more common in laparoscopic compared with open cholecystectomy. Subsequent infectious complications are often delayed, occurring in 0.1% to 2.9% of cases. We present the first reported case of Salmonella enterica subphrenic abscess and empyema complicating dropped gallstones, treated with video-assisted thoracoscopic surgery (VATS), and surgical retrieval. A 67-year-old male with symptomatic cholelithiasis underwent an uncomplicated laparoscopic cholecystectomy. Four years later, he presented with a mass in his right flank, and an abdominal computed tomography (CT) revealed a right flank intramuscular abscess containing gallstones. The abscess was drained surgically with removal of gallstones. He was readmitted 15 months later with right upper quadrant pain, fever, and dyspnea. Chest and abdominal computer tomography (CT) showed a right pleural effusion and a right subphrenic abscess containing a dropped gallstone. The gallstone was localized with a needle using CT guidance. He subsequently underwent a right VATS for decortication. A separate flank incision was made at the site of the needle to drain the subphrenic abscess and retrieve the gallstone. Cultures from his empyema grew S enteritidis. The patient made an uneventful recovery. During laparoscopic cholecystectomy, efforts should be made to retrieve dropped gallstones as they can cause abscess and empyema, which might necessitate furthermore surgical intervention. The use of VATS has been established as a safe and effective alternative to thoracotomy, including the treatment of empyema. Needle-localization resulted in a successful retrieval of the gallstone in our patient. Culture of the abscess is important, as unusual organisms such as Salmonella could be present. S. enteritidis has not been implicated as a cause of cholecystitis and is rarely associated with abdominal abscesses. We postulate that the organism reached the gallbladder through the bile or bloodstream after gastrointestinal colonization and that its persistence in the gallbladder may have been facilitated by gallstones.

Video-assisted thoracoscopic surgery in the management of penetrating and blunt thoracic trauma

BACKGROUND:The role of video-assisted Thoracoscopic Surgery (VATS) is still being defined in the management of thoracic trauma. We report our trauma cases managed by VATS and review the role of VATS in the management of thoracic trauma.MATERIALS AND METHODS:All the trauma patients who underwent VATS from 2000 to 2007 at Cedars-Sinai Medical Center were retrospectively studied.RESULTS:Twenty-three trauma patients underwent 25 cases of VATS. The most common indication for VATS was retained haemothorax. Thoracotomy was avoided in 21 patients. VATS failed in two cases. On an average VATS was performed on trauma day seven (range 1-26) and the length of hospital stay was 20 days (range 3-58). There was no mortality. VATS was performed in an emergency (day 1-2), or in the early (day 2-7) or late (after day 7) phases of trauma.CONCLUSION:VATS can be performed safely for the management of thoracic traumas. VATS can be performed before or after thoracotomy and at any stage of trauma. The use of VATS in trauma has a trimodal distribution (emergent, early, late), each with different indications.

Video-Assisted Thoracoscopic Cardiac Denervation: A Potential Novel Therapeutic Option for Children With Intractable Ventricular Arrhythmias

Left cardiac sympathetic denervation is one of the therapeutic modalities used in the management of patients with medically refractory long QT syndrome. Traditionally, a thoracotomy or cervical incision has been used as the standard surgical approach for performing left cardiac sympathetic denervation. Video-assisted thoracoscopic surgery allows a minimally invasive technique. There is only one published series on the use of video-assisted thoracoscopic surgery for left cardiac sympathetic denervation in patients with long QT syndrome. We performed a retrospective clinical review of pertinent medical records and report a series including 9 pediatric patients (4 long QT syndrome, 4 catecholaminergic polymorphic ventricular tachycardia, and 1 idiopathic ventricular tachycardia) who underwent a left cardiac sympathetic denervation by means of video-assisted thoracoscopic surgery. There were no severe complications, and 6 of 7 symptomatic patients with available follow-up experienced marked improvement in the first month after sympathectomy. This minimally invasive procedure provides a safe novel therapeutic option for children with drug-refractory catecholaminergic polymorphic ventricular tachycardia and other catecholamine-triggered arrhythmias.

Video-assisted Thoracoscopic Surgery: Is It a Superior Technique for the Division of Vascular Rings in Children?

The use of video-assisted thoracoscopic surgery (VATS) is becoming increasingly common in the treatment of congenital heart defects, particularly for the division of vascular rings. We compare the short-term outcomes of vascular ring division by VATS as opposed to open thoracotomy and discuss new issues raised by VATS division of vascular rings. Over a 3-year period, 47 pediatric patients underwent isolated division of a vascular ring. We reviewed preoperative, operative, and postoperative data. For patients whose vascular ring contained a ligamentous or atretic segment, comparisons were made between operations performed by open thoracotomy and by VATS. For the 47 patients, diagnoses included right aortic arch/aberrant left subclavian artery/left ligamentum arteriosum (25), double aortic arch/right dominant (19), and double aortic arch/left dominant (3). At the time of repair, ages ranged from 1.4 to 207 months (median 15.0) and weights ranged from 2.8 to 54.0 kg (median 11.0). The 29 patients with a vascular ring containing a ligamentous or atretic segment were included in the comparison between open thoracotomy and VATS. This included 25 patients with a right aortic arch, aberrant left subclavian artery, and ligamentum arteriosum, and 4 patients with a right dominant double aortic arch in which the left arch was atretic. Patients with patent rings requiring clamping and oversewing of the vessels were not included in the comparison. Thoracoscopic division was successful in 14/16 (88%) patients. There was no significant difference in the procedure time (P = .48) with the thoracoscopic approach. There were also similar times for intensive care unit stay (P = .25) and total length of hospital stay (P = .22). The division of vascular rings by VATS shows similar outcomes compared with the open thoracotomy approach. It is expected that, with an increase in comfort level and further improvements in technology, the use of VATS can be extended to include patients with other congenital heart defects.

Role of thoracoscopy in acute management of chest injury

To review the literature on the use of video-assisted thoracoscopic surgery for the diagnosis and treatment of intrathoracic injuries. Video-assisted thoracoscopic surgery is a relatively recent innovation. It was originally promoted for the treatment of retained hemothorax and the diagnosis of diaphragm injury. It is highly effective for the management of those problems. Recent studies have focused on video-assisted thoracoscopic surgery for treatment of chest wall bleeding, diagnosis of transmediastinal injuries, pericardial window and persistent pneumothorax. In properly selected patients, video-assisted thoracoscopic surgery is extremely efficacious in managing these problems. The role of video-assisted thoracoscopic surgery in the management of acute chest injury is expanding. It is an invaluable tool for the trauma surgeon.

Single-lung ventilation in infants and children.

During the past decade, the use of video-assisted thoracoscopic surgery (VATS) has dramatically increased in children as well as adults. Although VATS can be performed while both lungs are being ventilated, single-lung ventilation (SLV) is desirable during VATS. In addition, anaesthesiologists are performing (and paediatric surgeons are requesting) SLV more frequently for open thoracotomies in infants and children.

The Real Impact and Usefulness of Video-Assisted Thoracoscopic Surgery in the Diagnosis and Therapy of Clinical Lymphadenopathies of the Mediastinum

The aim of this study was to evaluate the impact of video-assisted thoracoscopic surgery (VATS) in the diagnosis and therapy of clinical mediastinal lymphadenopathies. In our Institute, from 1995 to 2001, 85 patients underwent VATS biopsy: 55 subjects (group 1) for suspected lung cancer (65%) and 30 (group 2) for unknown nodes enlargement (35%). Lymphonodes were considered suspected if > 1 cm by radiological imaging. We performed 83 thoracoscopic biopsies: 33 in level 5 (39%), 24 in level 6 (29%), 19 in level 7 (22%), and 7 in level 8 (8%). A histological analysis of frozen sections was made in every case. Twenty subjects underwent lung resection in one-time (24%). Histology in group 1 was adenocarcinoma in 28 cases, epidermoid carcinoma in 14, microcytoma in 9, and giant-cell carcinoma in 4. Ten patients were at stage I, 10 at stage II, 33 at stage III, and two at stage IV. Histology of group 2 was lymphoma in 18 cases, sarcoidosis in eight, and focal aspecific hyperplasia in four. The usefulness of VATS allowed the pathological assessment of the presumed involved mediastinal lymph nodes in every patient and thus permitted to assure in all the cases the indicated therapeutic treatment.

The Inadvisability of Thoracoscopic Lung Biopsy on Patients With Pulmonary Hypertension

The use of video-assisted thoracoscopic surgery (VATS) sometimes leads to additional and unnecessary risks compared with thoracotomy. We report a troubling case of VATS lung biopsy in a 43-year-old woman with mild pulmonary hypertension. A progressive elevation of pulmonary artery pressure (PAP) was noted after the commencement of right unilateral ventilation. When the systolic PAP reached 90 mm Hg (390 min after induction of anesthesia), a massive blood discharge through the chest drain occurred. At repeat thoracotomy, continuous blood spouting was seen from > 10 of the surgical sites. It was supposed that the endoscopic staplers were unable to maintain hemostasis with such a high PAP.

Video-assisted thoracoscopic surgery for diagnosis, staging, and management of lung cancer with suspected mediastinal lymphadenopathy.

The aim of this report was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) in staging, diagnosis, and treatment of lung cancer. Fifty-two patients were scheduled for mediastinal lymph node VATS biopsy at the Oncologic Thoracic Surgery Department of the National Cancer Institute in Milan. Fifty patients underwent lymph nodal thoracoscopic biopsy (96%), whereas for the other 2 patients, histologic diagnosis was done by pleural metastatic nodule thoracoscopic biopsy (4%). We performed 17 lymph nodal biopsies in level 5 (33%), 14 in level 6 (27%), 12 in level 7 (23%), and 7 in level 8 (13%). No postoperative complications were observed, and 19 subjects (36%) underwent open lung resection. The histologic diagnosis was adenocarcinoma in 25 cases (48%), epidermoid carcinoma in 14 (27%), microcytoma in 9 (17%), and giant-cell lung carcinoma in 4 (8%); 10 patients were at stage I (19%), 9 at stage II (17%), 31 at stage III (60%), and 2 at stage IV (4%). The use of VATS allowed diagnosis of the suspected involved mediastinal lymph nodes in lung cancer patients and obviated the need for painful thoracotomy, enabling accurate staging and thus selection of the optimal treatment.

Outcome after unilateral lung volume reduction surgery in patients with severe emphysema.

Bilateral lung volume reduction surgery (LVRS) has emerged as a palliative treatment option in patients with severe pulmonary emphysema. However, it is not known if a sustained functional improvement can be obtained using an unilateral approach. We hypothesized that a palliative effect can also be obtained by unilateral LVRS and prospectively assessed lung function, walking distance, and dyspnea before and 3, 6, 12, 18, 24 and 36 months after unilateral LVRS. Twenty-eight patients were operated by the use of video-assisted thoracoscopic surgery (VATS) with a mean follow-up of 16.5 months (range 3-36 months). Forced expiratory volume in 1 s (FEV1) was significantly improved up to 3 months (1007+/-432 compared to 1184+/-499 ml, P<0.001), residual volume up to 24 months (4154+/-1126 compared to 3390+/-914 ml, P<0.01), dyspnea up to 12 months (modified Borg dyspnea scale 6.6+/-1.8 compared to 3.9+/-1.8, P=0.01) and walking distance up to 24 months (343+/-107 compared to 467+/-77 m, P<0.05) after unilateral LVRS compared to preoperative values. Overall, 25 of 28 patients reported a subjective benefit after unilateral LVRS. There was no 30-day mortality. Only two patients required surgery on the contralateral side after 4.5 and 6 months, respectively, both suffering from alpha-1-antitrypsin deficiency. Unilateral LVRS by the use of VATS results in a sustained beneficial effect, improving walking distance and dyspnea for up to 24 months in patients with severe emphysema. The preservation of the contralateral side for future intervention if required renders unilateral LVRS an attractive concept in this difficult palliative situation.