Video-assisted Thoracic Operations Research Articles

Surgical tactics for benign bronchial and lung tumors

Aim: to identify the efficient surgical tactics in case of benign broncho-pulmonary tumors taking into account co-morbidities and possibilities of video-assisted thora- cic operations. Materials and methods. Among 133 pa- tients with benign tumors of the lungs and bronchi 128 (96%) had tumors of peripheral localization, 5 (4%) — of the central one. All patients with peripheral tumors were operated on. Charlson index was used to assess the co-morbidity. Results. In 120 (90.2%) patients tumors were diagnosed during routine Х-ray examination or casual check-up.6 (4.5%) patients showed clinical symp- toms. The average terms of observation of patients with peripheral tumors were 7.8 months (Me — 6, Q1 — 2, Q3 — 7), with the central ones — 13.3 months (Me — 5, Q1 — 3, Q3 — 8). In 4 cases central tumors were removed by endoscopy methods using electroresection and argon plasma coagulation. In one case a stent was inserted. More than 2/3 of patients had co-morbid pathologies. Charlson index in co-morbid patients was 2.4±1.4, in the group of patients elder than 70 years — 4.8±0.9. All patients with peripheral tumors were operated on. The video thoracoscopy approach was used in 56 (42.1%) pa- tients, thoracotomy — in 67 (50.4%), video-assisted mi- nithoracotomy — in 6 (4.5%). In 5.2% of cases thoracosco- py was converted to thoracotomy. All peripheral tumors were mesenchymal ones. Post-operative complications developed in 7 (5.5%) patients. There were no mortality. Conclusion. Peripheral benign tumors of the lungs are asymptomatic and require urgent surgery with an express histology test to rule out lung cancer. Central tumors are mostly removed by endoscopy. Video thoracoscopy is the most efficient method to remove peri pheral tumors. Conversion to thoracotomy is usually necessary in case of a small size and deep tumor localization.

Increasing Use of Video-Assisted Thoracic Operation in the Treatment of Congenital Pulmonary Lesions: Evaluating Trends in Operative Management and the Effect on Outcomes in NSQIP Pediatric

Arshad, Seyed MD; Ferguson, Dalya MD; Elise Hatton, Gabrielle MD; Li, Linda MD; Thomas Austin, Mary MD, FACS; Loraine Kawaguchi, Akemi MD, FACS; Jen Tsao, Kuo MD, FACS Author Information

The effects of different inspired oxygen concentration on the pulmonary collapse and postoperative recovery of thoracoscopic surgery

Objective To investigate the effect of different inhalation oxygen concentration on the lung collapse and postoperative recovery of thoracoscopic surgery. Methods Patients who underwent elective thoracoscopic radical resection of lung cancer were randomly divided into group A (n=29) and group B (n=30). Patents in the group A received a gas mixture of oxygen and air (FiO2=50%) whereas and patients in the group B received 100% oxygen(FiO2=100%) until the start of one lung ventilation (OLV). Then, the dependent lungs were ventilated with 50% oxygen during OLV in both groups. The surgeon evaluated the lung collapse using LCS score and Campos score for lung collapse. They were scaled at 1 min after the opening of the pleura(T0), 10 min after the start of OLV (T1), 20 min after the start of OLV (T2) and 30 min after the start of OLV (T3). During two lungs ventilation, arterial blood gases were measured before anesthesia induction, at 10, 20, 30 min after initiation of OLV. The incidence of postoperative atelectasis by chest CT at the third day after operation, hospital length of stay(LOS) and the incidence of patchy consolidation were recorded. Results At T1 and T2, the LCS scores and Campos scales of group B were higher than scores of group A (P 0.05). The oxygen partial pressure of group B was higher than that of the group A before 20 min of OLV, but the difference were not significant after 20 min. The incidence of postoperative atelectasis, LOS and the incidence of patchy consolidation were not different (P>0.05) Conclusions The inhalation of 100% oxygen before the OLV can make the pulmonary collapse effect better, and it has no effect on postoperative recovery. Key words: Video assisted thoracic operation; Pulmonary collapse; Fraction of inspired oxygen; One lung ventilation

Invited Commentary

This article from Heits and colleagues [1] looks at 10 patients who were treated after acquiring a perforated esophagus through placement of a polyurethane sponge into the cavity and transnasal application of an external vacuum connected to the sponge (EVT). Half of the patients required pleural drainage with a chest tube, and only 1 patient required a video-assisted thoracic operation. With this strategy, they reported successful healing in 9 of the 10 patients using this novel device. Although 2 patients had their treatments switched to esophagectomy (n = 1) and stenting (n = 1), these alternatives were not undertaken because of failure of the device.

A Case of Needle Embolism

FE A T U R E A R T IC L Awith right-sided chest pain and malaise. His last use of heroin was 3 days before presentation, and he reported injecting into the left side of his groin. The computed tomographic scan seen in Fig 1 was obtained and clearly demonstrates a right middle lobe consolidation with central thin linear hyperdensity measuring approximately 1 11 mm. The hyperdensity is evident in the course of the distal pulmonary artery. On further questioning, the patient remembered recently having a needle fragment break. He wished to have this removed and thus was taken to the operating room where a right video-assisted thoracic operation was

Nonintubated Needlescopic Video-Assisted Thoracic Surgery for Management of Peripheral Lung Nodules

Video-assisted thoracic operations are usually performed with 5-mm or 10-mm instruments under general anesthesia with single-lung ventilation. Management of peripheral lung nodules by a needlescopic video-assisted thoracoscopic operation, without endotracheal intubation, has rarely been attempted. We evaluated the feasibility and safety of this minimally invasive technique in managing peripheral lung nodules. From August 2009 through March 2011, 46 patients with peripheral lung nodules were treated using 3-mm needlescopic video-assisted thoracoscopic operations for wedge resection with epidural anesthesia and sedation, without endotracheal intubation. A definitive diagnosis was obtained in all 46. Extension of the 3-mm incisions was required in 8 patients because of primary lung cancer requiring a lobectomy in 3, pleural adhesions in 3, and difficulty in identifying or resecting the nodule in 2. Two patients required conversion to intubated single-lung ventilation because of dense adhesions between the lungs and the diaphragm. Operations lasted a mean of 69.2 ± 46.8 minutes. Postoperative side effects occurred in 4 patients, including sore throat, headache, and vomiting requiring medication. Operative complications developed in 1 patient who had air leaks for more than 3 days postoperatively. The mean postoperative chest tube drainage and hospital stay were 1.1 days and 2.7 days, respectively. Postoperative neuralgia was noted in 12 patients (26%). Most patients (74%) were very satisfied or satisfied with the resulting scars. Nonintubated needlescopic video-assisted thoracoscopic operations are technically feasible and safe and may be a less invasive alternative in the management of selected patients with peripheral pulmonary nodules.

Video-assisted thoracic surgery utilizing local anesthesia and sedation

Video-assisted thoracic surgery (VATS) is usually performed with general anesthesia and double-lumen endotracheal intubation, but minor procedures have been carried out with patients spontaneously breathing and with epidural or regional analgesia. We have broadened our indications for VATS utilizing purely local anesthesia and sedation. The medical records of all patients undergoing VATS under local anesthesia and sedation at Geisinger Wyoming Valley Medical Center between 7/1/02 and 6/1/06 were reviewed. All procedures were performed in the operating room with patients in full lateral position; no patient had endotracheal intubation or epidural or nerve block analgesia. One hundred and fifteen patients, ranging in age from 21 to 88 years and in size from 40 to 172 kg, underwent 126 video-assisted thoracic operations: pleural biopsy/effusion drainage with or without talc 81, drainage of empyema 21, lung biopsy 18, evacuate hemothorax 3, pericardial window 2, biopsy chest wall mass 1. No patient required intubation or conversion to thoracotomy. Three patients who underwent lung biopsy died of their underlying disease (cytomegalovirus and pneumocystis, primary amyloidosis, metastatic cancer to contra-lateral lung) on postoperative days 18, 14, and 4, respectively. One patient developed transient renal insufficiency attributed to ketorolac. VATS utilizing local anesthesia and sedation is well tolerated, safe, and valuable for an increasing number of indications.

Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery

A new method of marking small pulmonary nodules situated deep within the visceral pleura using a transbronchial approach has been developed. Once the tip of the sheath catheter has passed the tumor and reached the visceral pleura, as confirmed by computed tomography fluoroscopy, indigo carmine is injected through a bronchoscope into the lung parenchyma just beneath the visceral pleura. No complications related to the procedure were experienced. The dye-marking procedure enabled the nodules to be precisely located. This technique can provide appropriate guidance when used in conjunction with video-assisted thoracic operations.

Video-assisted thoracoscopy in the treatment of pleural empyema: Stage-based management and outcome

Objective: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. Methods: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8–82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. Results: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7.1 days (range, 4–140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. Conclusions: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice. (J Thorac Cardiovasc Surg 1999;117:234-8)

Thoracoscopic Operation for Secondary Pneumothorax Under Local and Epidural Anesthesia in High-Risk Patients

Background. Video-assisted thoracic operations usually require single-lung ventilation under general anesthesia. However, for high-risk patients with other underlying pulmonary diseases, one has to consider risks of general anesthesia itself. Methods. Four high-risk patients (4 men; mean age, 73 years) with intractable secondary pneumothorax and other underlying pulmonary diseases were treated by video-assisted thoracic operations under local and epidural anesthesia. Absorbable polyglycolic acid sheets and fibrin glue were used to control the air leakage. Results. The mean duration of the procedure was 108 minutes. Pain and cough reflex were well controlled, and spontaneous breathing and hemodynamics were well maintained during the operation. The mean duration of the postoperative chest drainage was 5 days. No significant postoperative complication was encountered. No pneumothorax had recurred at a mean follow-up of 16 months. Conclusions. Video-assisted thoracic operations can be performed safely under local and epidural anesthesia for the treatment of intractable secondary pneumothorax in high-risk patients. The air leakage can be controlled with the use of polyglycolic acid sheets and fibrin glue without bullectomy.

Videothoracoscopy and video-assisted small thoracotomy for the treatment of pulmonary malignancies: Casadio C, Giobbe R, Cianci R, Molinatti M, Oliaro A, Maggi G. Department of Thoracic Surgery, University of Turin, Via Genova 3, 10126 Turin. J Cardiovasc Surg 1994;35:445–448

Video-assisted thoracic surgical procedures continue to be performed with increased frequency; the role of this new technique in the treatment of pulmonary malignancies or metastatic mediastinal adenopathies is not yet defined. Out of a series of 100 consecutive video-assisted thoracic operations, 22 patients resulted affected by a malignancy in the lung or in the subcarinal lymphnodes: six patients had a primary lung cancer and were operated with a video-assisted small thoracotomy of 5 cm (three lobectomy and three segmentectomy) because of a very poor respiratory reserve. Nine patients received a video-assisted wedge resection of a nodule resulted at the frozen section a metastasis of a carcinoma: a small thoracotomy of 8 cm was made and a hand entered the thoracic cage to obtain a careful palpation of the entire lung; five patients had enlarged lymphnodes only in posterior and inferior mediastinum, inaccessible by cervical mediastinoscopy or anterior mediastinotomy: thoracoscopic exploration obtained a useful mediastinal nodal sampling for these adenopathies. In selected cases video-assisted thoracic surgery can be used for resection or assessment of thoracic malignancies.

Tumor implants after thoracoscopic resection of a metastatic sarcoma

Tumor implantation after video-assisted thoracic operations is rare. We describe the case of a 61-year-old woman who underwent an apparently uneventful thoracoscopic resection of a solitary pulmonary metastasis from a primary limb sarcoma. Within 3 months, extensive trocar and diaphragmatic implants developed that required an extensive en bloc resection of her chest wall, diaphragm, and lung. Because of the aggressive biologic behavior of sarcomas and their potential to grow in surgical tracts, concern is raised about the advisability of using video-assisted thoracic surgical techniques in the management of these tumors.

Use of video-assisted thoracic surgery in the treatment of chylothorax

Chylothorax, a potentially lethal disorder that may cause profound respiratory, nutritional, and immunologic complications, has become increasingly common in recent yeara. Medical therapy has been found to have a significant failure rate. Therefore, surgical treatment of complicated chylothorax has become a mainstay of care. Between 1987 and 1993, ten patients at the University of Virginia Hospital were treated with video-assisted thoracic surgery for complicated chylothorax. Twelve thoracoscopic procedures were performed. Patients ranged in age from 7 months to 82 years. Causes included iatrogenic (2), congenital (2), caval thrombosis (2), amyloid (2), blunt trauma (1), and metastatic carcinoid tumor (1). In 10 cases, video-assisted thoracic surgery was employed as the principal mode of therapy: 8 using talc pleurodesis alone, 1 using talc pleurodesis and clipping of the thoracic duct with application of fibrin glue, and 1 requiring clipping of a pleural defect with application of flbrin glue. In 2 cases, a video-assisted thoracic operation was used in conjunction with pleuroperitoneai shunting: a previously placed pleuroperitoneal shunt that was malfunctioning was repositioned thoracoscopically after a pleural adhesiolysis, and a pleural adhesiolysis was performed thoracoscopically before placement of a pleuroperitoneal shunt. In all cases the effusion resolved after the video-assisted thoracic operation without further intervention. Video-assisted thoracic surgery offers an effective means of treating chylothorax, regardless of cause, allowing the advantage of access to thoracic structures without the morbidity of more extensive procedures.

Diagnostic and therapeutic thoracoscopy: Lessons from the learning curve

A variety of video-assisted thoracic operations are being reported with increasing frequency. Problems encountered during the development of this technology have received less attention. During the course of 27 months, 69 consecutive patients underwent minimally invasive procedures at our institution. Conversion to thoracotomy was required in 16 of 49 (33%) patients undergoing diagnostic procedures and 1 of 20 (5%) patients undergoing therapeutic interventions. Fewer complications occurred in those patients with diagnostic procedures (10 of 49, 20%) versus therapeutic interventions (10 of 20, 50%; p = 0.01). Logistic regression analysis showed chronic obstructive pulmonary disease to be an independent risk factor for complications. The mean postoperative stay was 7.9 +/- 6.8 days for diagnostic and 12.8 +/- 9.7 days for therapeutic interventions (p = 0.02). As new technologic improvements were introduced, the mean hospital stay decreased (first 10 months: 14.6 +/- 10.0 days, 10 to 20 months: 9.8 +/- 9.6 days, more than 20 months: 5.2 +/- 3.0 days, p < 0.004). The surgeon's thoracoscopic experience was not as strongly predictive (5 or fewer cases: 8.9 +/- 5.9 days, 6 to 15 cases: 13.1 +/- 12.6 days, more than 15 cases: 5.0 +/- 2.0 days). Although thoracoscopic surgery is promising, the potential for problems requires careful surgical judgment and expertise in dealing with thoracic complications.

One hundred consecutive patients undergoing video-assisted thoracic operations : Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. 185 Livingston Avenue, New Brunswick, NJ 08901. Ann Thorac Surg 1992;54:421–426

One hundred consecutive patients undergoing video-assisted thoracic operations : Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. 185 Livingston Avenue, New Brunswick, NJ 08901. Ann Thorac Surg 1992;54:421–426

One hundred consecutive patients undergoing video-assisted thoracic operations

Video-assisted thoracic surgery is a new modality that allows visualization of and access to the intrathoracic organs without making a thoracotomy incision. One hundred consecutive patients underwent 113 thoracic procedures using this technique. Eight wedge resections for metastatic lesions, 6 pericardial windows, 1 bronchogenic cystectomy, 4 explorations of the aortopulmonary window, 1 decortication, 5 pleural scleroses, 8 bullous ablations, 25 lung biopsies, 19 wedge resections for carcinoma, 9 explorations of the thorax, 3 lobectomies, 1 esophageal cystectomy, 14 wedge resections for benign lesions, 4 pleurectomies, 1 excision of a neurogenic tumor, 3 mediastinal explorations, and 1 imaged axillary dissection were performed. There was no mortality. Ten patients had complications from which they recovered completely. Patients undergoing video-assisted thoracic operations seem to have reduced post-operative pain, shorter hospitalization, and quicker recovery times. Currently, this new modality appears to have beneficial value for patients; however, only further experience will determine its true merits.