Video-assisted Thoracic Surgical Research Articles

The Clinical Outcomes of Thoracoscopic Versus Open Lobectomy for Non–Small-Cell Lung Cancer After Neoadjuvant Therapy: A Multi-Center Retrospective Cohort Study

BackgroundThe safety and efficacy of video-assisted thoracic surgical (VATS) versus open lobectomy for non–small-cell lung cancer (NSCLC) following neoadjuvant therapy remained controversial. The aim of this study was to compare the outcomes of VATS with those of open lobectomy for NSCLC after neoadjuvant therapy. MethodsPatients who had undergone VATS or open lobectomy for NSCLC following neoadjuvant therapy in nine hospitals in China from July 2014 to July 2020 were retrospectively reviewed. The clinical characteristics and overall survival (OS) of patients were analyzed using Cox regression models and propensity score matching. ResultsWe identified 685 patients, 436 (63.6%) who had undergone VATS lobectomy and 249 (36.4%) who had undergone open lobectomy. Patients who had undergone VATS lobectomy tended to have had fewer nodes removed than those who had undergone open lobectomy. However, compared with open group, the VATS group had a better perioperative outcome, such as smaller blood loss volumes and shorter postoperative stays. The groups had a similar operation durations and postoperative complications, and there was a nonsignificant difference between their 30-day mortality rates. After propensity score matching, there was no significant different between the OS of the groups, and only postoperative adjuvant therapy was associated with worse OS. ConclusionThis multi-center analysis of patients with NSCLC who had undergone surgery subsequent to neoadjuvant therapy reveals that VATS lobectomy tended to have a better perioperative outcome, and have a similar OS compared to open lobectomy. These findings suggest that VATS lobectomy is appropriate for NSCLC following neoadjuvant therapy.

Pathologic comparison of conventional video-assisted thoracic surgical (VATS) biopsy versus non-intubated/“awake” biopsy in fibrosing interstitial lung diseases

Surgical lung biopsy remains the standard procedure for the subset of patients with fibrosing interstitial lung disease (F-ILD) who require a lung biopsy to secure a confident diagnosis. Little is known about the pathologic features of samples obtained via non-intubated/“awake” surgical lung biopsy and the diagnostic accuracy of awake biopsy in patients with F-ILD. Two expert thoracic pathologists blinded to the type of lung biopsy compared the clinical-pathologic features of 120 conventional VATS biopsies with those of 21 consecutive non-intubated/“awake” VATS biopsies. No statistically significant differences between the two procedures were observed with regard to identification of histopathological features. Biopsy length, average of sampled lobes and mean number of slides were similar with the two procedures, while the width of the biopsies was significantly deeper with conventional VATS (31.5 mm versus 25.6 mm; p = 0.01). By contrast, the mean age of patients (69.5 versus 64.5 years; p = 0.02) and the level of diagnostic confidence (100% versus 75%; p = 0.007) were significantly higher among patients undergoing the “awake” procedure. Diagnostic yield was 100% in both groups, with a similar distribution of ILD diagnoses. Non-intubated/“awake” biopsy has the potential to become the standard surgical procedure in patients with F-ILD requiring a histological confirmation of their diagnosis. However, larger prospective studies are needed to validate the safety and diagnostic yield of “awake” compared to conventional VATS.

Video-Assisted Thoracic Surgical Right Upper Lobectomy with Bronchus-First and Simultaneous Vessel Stapling Technique.

A method of video-assisted thoracic surgical (VATS) right upper lobectomy with bronchus-first and simultaneous vessel stapling will be introduced. In this study, all cases underwent two-port VATS as follows: first, the right upper lobe bronchus was identified and stapled; then, all right upper lobe vessels were stapled simultaneously. This method was performed in 50 cases. There was no surgical mortality, hemorrhage, vascular injuries, or conversion. This technique can reduce wound size and operative time and make the operation safer and easier to accomplish.

Video-Assisted Thoracic Surgical Lobectomy for Lung Cancer: Description of a Learning Curve.

Video-assisted thoracic surgical (VATS) lobectomy is gaining popularity in the treatment of lung cancer. The aim of this study is to investigate the learning curve of VATS lobectomy by using multidimensional methods and to compare the learning curve groups with respect to perioperative clinical outcomes. We retrospectively reviewed a prospective database to identify 67 consecutive patients who underwent VATS lobectomy for lung cancer by a single surgeon. The learning curve was analyzed by using moving average and the cumulative sum (CUSUM) method. With the moving average and CUSUM analyses for the operation time, patients were stratified into two groups, with chronological order defining early and late experiences. Perioperative clinical outcomes were compared between the two learning curve groups. According to the moving average method, the peak point for operation time occurred at the 26th case. The CUSUM method also showed the operation time peak point at the 26th case. When results were compared between early- and late-experience periods, the operation time, duration of chest drainage, and postoperative hospital stay were significantly longer in the early-experience group (cases 1 to 26). The intraoperative estimated blood loss was significantly less in the late-experience group (cases 27 to 67). CUSUM charts showed a decreasing duration of chest drainage after the 36th case and shortening postoperative hospital stay after the 37th case. Multidimensional statistical analyses suggested that the learning curve for VATS lobectomy for lung cancer required ∼26 cases. Favorable intraoperative and postoperative care parameters for VATS lobectomy were observed in the late-experience group.

Effects of transcutaneous electrical acupoint stimulation at different frequencies on perioperative anesthetic dosage, recovery, complications, and prognosis in video-assisted thoracic surgical lobectomy: a randomized, double-blinded, placebo-controlled trial.

Transcutaneous electrical acupoint stimulation (TEAS), a non-invasive and non-pharmacological adjunctive intervention for perioperative analgesia, may also reduce the incidence of postoperative pulmonary complications. The effect of TEAS on video-assisted thoracic surgical (VATS) patients is still unknown, however. The purpose of this study was to investigate the effects of TEAS of different frequency on perioperative anesthetic dosage, recovery, complications, and prognosis for patients undergoing VATS lobectomy. Eighty VATS lobectomy patients with no previous experience of TEAS or acupuncture were randomly assigned to four groups: control (con), 2/100, 2, and 100Hz. The last three experimental groups received TEAS at the indicated frequencies for 30min before induction, during the operation, and for another 30min 24 and 48h after surgery. 2/100Hz is a type of alternating frequency which goes between 2 and 100Hz every 3s. TEAS was administered over acupoints Neiguan, Hegu, Lieque, and Quchi on the sick lateral. Electrodes were applied to the patients in the control group, but no TEAS was used. Anesthetic dosage, blood gas analysis results, lung function indexes FEV1 and FVC, post-anesthesia care unit (PACU) status, postoperative complications, and quality of life scores were recorded and analyzed statistically. Intraoperative opioid consumption was lowest in the 2/100Hz group, with statistical significance (con, P≤0.001; 2Hz, P≤0.001; 100Hz, P=0.026). Compared with preoperative FEV1 and FVC, postoperative FEV1 and FVC were significantly lower in all groups; during one-lung ventilation, arterial oxygen partial pressure (PaO2) decreased more slowly in the 2/100Hz group than in the con group (P=0.042). Moreover, in the 2/100Hz group extubation time was shorter (P=0.038), visual analgesia scale score lower (P=0.047), and duration of PACU stay shorter (P=0.043) than in the con group. In the 100Hz group incidence of postoperative nausea and vomiting (PONV) was lower than the con group (P=0.044). In all groups mean postoperative physical component scores were significantly lower than mean preoperative scores. TEAS is a safe noninvasive adjunctive intervention for anesthesia management among patients undergoing VATS lobectomy. TEAS at 2/100Hz can reduce intraoperative opioid dosage and slow the decrease of PaO2 during one-lung ventilation. It can also effectively reduce pain score, extubation time, and PACU stay immediately after surgery. Further, 100Hz TEAS can reduce PONV morbidity.

Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: Are there outcomes advantages?

To determine if there are advantages to transitioning to robotics by a surgeon who is already proficient in performing video-assisted thoracic surgical (VATS) lobectomy. A single surgeon proficient in VATS lobectomy initiated a robotic lobectomy program, and a retrospective review was conducted of his patients undergoing minimally invasive lobectomy (robotics or VATS) for lung cancer between 2011 and 2012. Data collected included patient/tumor characteristics, morbidity, mortality, operative times, and length of hospital stay. Over a 24-month period, a total of 69 patients underwent minimally invasive lobectomy (35 robotic, 34 VATS). Patients in each group were similar in age and clinical stage. Robotic upper lobectomy operative times were longer than VATS (172 vs 134 minutes; P = .001), with no significant difference in lower lobectomies noted (140 vs 123 minutes; P = .1). Median length of stay was 3 days in both groups, and the median number of lymph nodes harvested was 18 (robotic) versus 16 (VATS; P = .42). Morbidity and mortality for robotic versus VATS were 11% versus 18% (P = .46) and 0% versus 3% (P = .49), respectively. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes. The learning curve for robotic upper lobectomies seems to be more significant than that for lower lobectomies.

Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: Results from a multihospital database (Premier)

Video-assisted thoracic surgical (VATS) lobectomies and wedge resections result in less morbidity and shorter length of stay than resections via thoracotomy. The impact of robot-assisted thoracic surgical (RATS) lobectomy on clinical and economic outcomes has not been examined. This study compared hospital costs and clinical outcomes for VATS lobectomies and wedge resections versus RATS. Using the Premier hospital database, patients aged ≥18 years with a record of thoracoscopic lobectomy, segmental resection, or excision of a lesion or tissue from the lung between 2009 and 2011 were identified. Procedures using robotic technology were identified if 1 of 2 conditions were met: (1) a robotic International Classification of Diseases, Ninth Revision procedure code or (2) the text fields in the hospital record indicated that the robot was used. Using a propensity score and based on severity and comorbidities, certain demographics and hospital characteristics were matched. The association between VATS or RATS and adverse events, hospital costs, surgery time, and length of stay was examined. Of 15,502 patient records analyzed, 96% (n=14,837) were performed without robotic assistance. Using robotic assistance was associated with higher average hospital costs per patient. The average cost of inpatient procedures with RATS was $25,040.70 versus $20,476.60 for VATS (P=.0001) for lobectomies and $19,592.40 versus $16,600.10 (P=.0001) for wedge resections, respectively. Inpatient operating times were longer for RATS lobectomy than VATS lobectomy (4.49 hours vs 4.23 hours; P=.0959) and wedge resection (3.26 vs 2.86 hours; P=.0003). Length of stay was similar with no differences in adverse events. RATS lobectomy and wedge resection seem to have higher hospital costs and longer operating times, without any differences in adverse events.

Non-muscle invasive transitional cell carcinoma of the distal ureter and bladder with lung metastasis: A case report and literature review

INTRODUCTIONNon-muscle invasive transtitional cell carcinoma (TCC) with metastases is exceedingly rare. PRESENTATION OF CASEWe report the case of a 78-year old man with an incidental finding of a non-muscle invasive TCC of the left distal ureter during treatment for Duke's B Colon cancer. Following laparoscopic nephro-ureterectomy (LNU) he had two further superficial recurrences in the bladder over a 14-month period which underwent transurethral resection (TUR). On surveillance imaging for his colorectal cancer follow-up a lung nodule was detected and video-assisted thoracic surgical (VATS) resection of the lesion showed it to be TCC in origin. He was referred to oncology for chemotherapy and remains clinically well. DISCUSSIONA Literature search found only three other such cases and the ureteric TCC is the most likely source of the metastasis. CONCLUSIONThis occurrence is exceedingly rare.

Disparities in Access to Video-Assisted Thoracic Surgical Lobectomy for Treatment of Early-Stage Lung Cancer

Video-assisted thoracic surgical (VATS) lobectomy was originally described in 1992 and has slowly gained increasing acceptance. This study documents current utilization and outcomes for VATS versus open lobectomy in three Mid-Atlantic states. Inpatient discharge claims data were queried for all lobectomies performed for cancer in the Mid-Atlantic United States (New Jersey, New York, and Pennsylvania) between October 2007 and December 2008. Associations between sociodemographic factors and likelihood of undergoing VATS were tested with multiple logistic regressions. Outcomes were compared using two-sample t tests. There were 5489 lobectomies included. Forty-seven percent of patients were men, and 62% were ≥65 years old. Thirty-two percent (1741 of 5489) were VATS lobectomies. Men were less likely to undergo VATS (odds ratio 0.86, P=.004); those ≥65 years old were more likely to undergo VATS (odds ratio 1.34, P=.009). Uninsured patients underwent VATS less often (odds ratio 0.46, P=.01). Patients from rural areas were less likely to undergo VATS (odds ratio 0.67, P=.001), although travel distances for both groups were similar. A total of 44% of these hospitals (125 of 284) performed only open lobectomies. Patients without private insurance or Medicare were less likely to undergo a VATS lobectomy (P=0.01). In general, the likelihood of VATS lobectomy increased as hospital lobectomy volume increased. VATS patients had a shorter median length of stay (5 versus 6 days, P<.001) and a higher rate of discharge to home (92.5% versus 89.5%, P<.001). Mean total hospital costs were less for VATS patients ($49,948 versus $56,280, P<.001). In-hospital mortality was less for VATS patients (1.2% versus 2.1%, P=.013). For the period studied, patients in rural areas, in low-volume hospitals, who had Medicaid, or with lower median incomes underwent VATS lobectomy less often.

PSU11 Comparing Robot-Assisted to Conventional Video-Assisted Thoracic Surgical (VATS)Lobectomy and Wedge Resection: Results from a Multi-Hospital (Premier) Database

PSU11 Comparing Robot-Assisted to Conventional Video-Assisted Thoracic Surgical (VATS)Lobectomy and Wedge Resection: Results from a Multi-Hospital (Premier) Database

Action point: intraoperative lymph node staging

When performing a lung cancer resection in patients who are technically and functionally operable, complete resection remains a major prognostic factor. Although still a controversial topic, specific criteria have been published to precisely define a complete resection [1]. These include that a systematic nodal dissection has been performed or at least, a lobe-specific nodal dissection. In both instances removal of at least six lymph node stations is required, of which three have to be in the mediastinum. Also, the highest mediastinal lymph node should be negative on definitive pathological examination. The European Society of Thoracic Surgeons (ESTS) published guidelines for preoperative and intraoperative lymph node staging in order to guide surgeons in performing a thorough lymph node evaluation [2, 3]. In almost all recent papers on lung cancer resection, the authors mention that these specific guidelines were carefully followed. In the present manuscript, the completeness of mediastinal nodal dissection was evaluated in four major hospitals in the Netherlands, three community and one university hospital [4]. All surgeons had a specific certification in thoracic surgery. The results are surprising: in only 36% of the patients at least three mediastinal lymph node stations were removed. Even more disturbing was the fact that a complete lymph node dissection according to the ESTS guidelines was performed in only 4% of patients. No difference was found between cardiothoracic and general surgeons with an additional certification in thoracic surgery. This clearly implies that many patients were understaged and that even the pathological tumour–node–metastasis (TNM) classification cannot be considered to be accurate. Although this is a retrospective cohort analysis in a relatively small number of patients, this study demonstrates that we do not live in an ideal world and that in daily practice guidelines are not adequately followed. This seems to be a generalized problem and similar figures were reported in other studies. This not only relates to intraoperative nodal dissection but also to invasive staging and in a specific study lymph node biopsies were taken in <50% of patients undergoing mediastinoscopy [5]. The main question is why even dedicated thoracic surgeons are so reluctant to perform a thorough mediastinal lymph node dissection. Admittedly, operative time is somewhat increased and there is a risk of intraoperative bleeding from major structures as the azygos vein or superior vena cava, and a higher risk of chylous leakage from cut mediastinal lymphatic vessels. The subcarinal zone is more difficult to reach, especially when performing a video-assisted thoracic surgical (VATS) procedure. Do thoracic surgeons rely on integrated computed tomographicpositron emission tomographic (CT-PET) scanning or the recently introduced minimally invasive techniques as endoscopic and endobronchial ultrasound? Is formal lymph node dissection not necessary anymore when you have performed a mediastinoscopy preoperatively, although not all mediastinal lymph node stations are within reach of the mediastinoscope and the false negative rate is 10%? Financial issues may also be involved and recently, in Belgium reimbursement has been increased when a systematic nodal dissection is performed during lung cancer resection. The recently published American College of Surgery Oncology Group (ACOSOG) Z0030 phase III trial showing no difference in survival in patients with clinical T1-2, non-hilar N1 non-small cell lung cancer who were randomized between lymph node sampling and systematic nodal dissection, is misinterpreted by many surgeons and oncologists [6]. It should be stressed that these patients had a thorough pathologic evaluation of four nodal stations, of which three had to be in the mediastinum, before they were randomized. This is certainly not current practice in many thoracic centres and so, the results of the ACOSOG trial cannot be generalized. The main message of the present study is that further education and training of thoracic surgeons, residents and fellows is necessary to increase the accuracy of intraoperative lymph node staging. Major thoracic surgical associations have the obligation to address this topic in their annual programme, educational and postgraduate sessions. Hopefully, the new nodal map introducing the concept of nodal zones grouping several lymph node stations, will increase the awareness of the importance of nodal staging and improve the overall quality of our surgical practice [7].

Development of Bullous Disease during Treatment of Pulmonary Marginal Zone B-Cell Lymphoma

We describe an unusual case of severe pulmonary bullous disease developing during treatment of marginal zone B-Cell lymphoma (MALT) involving the pulmonary parenchyma. The patient originally presented with pneumonia-like symptoms along with hemoptysis and was diagnosed with MALT lymphoma after a video-assisted thoracic surgical (VATS) lung biopsy. Computed tomography (CT) of the chest at diagnosis revealed multiple opacities, but no bullous disease. During the ensuing 4 years, and while on chemotherapy for the MALT lymphoma, sequential CT and pulmonary function tests revealed the development of progressive bullous disease resulting in the replacement of large portions of the lung parenchyma with bilateral bullae. This complication is rare, has been reported only once before in a patient with concomitant amyloidosis, and may be related to activation of proteolytic enzymes by lymphoma cells or chemotherapeutic agents.

Reversed halo sign on thin-section CT in a patient with non-specific interstitial pneumonia

We present a case of non-specific interstitial pneumonia (NSIP) with reversed halo sign on thin-section CT. A 52-year-old female presented with a cough and New York Heart Association (NYHA) class 2 dyspnoea of 4 months duration. A chest radiograph showed poorly defined, patchy ground-glass opacities in both lungs. Thin-section CT demonstrated the reversed halo sign, which is a central ground-glass opacity surrounded by crescent or ring-shaped areas of consolidation in multifocal areas. Multifocal patchy ground-glass opacity and consolidation and enlarged paratracheal, hilar and subcarinal lymph nodes were also shown. Video-assisted thoracic surgical (VATS) lung biopsy was performed, and histopathology revealed cellular NSIP.

A comparison of perioperative outcomes of Video-Assisted Thoracic Surgical (VATS) Lobectomy with open thoracotomy and lobectomy: Results of an analysis using propensity score based weighting

BackgroundRandomized trials comparing VATS lobectomy to open lobectomy are of small size. We analyzed a case-control series using propensity score-weighting to adjust for important covariates in order to compare the clinical outcomes of the two techniques.MethodsWe compared patients undergoing lobectomy for clinical stage I lung cancer (NSCLC) by either VATS or open (THOR) methods. Inverse probability of treatment weighted estimators, with weights derived from propensity scores, were used to adjust cohorts for determinants of perioperative morbidity and mortality including age, gender, preop FEV1, ASA class, and Charlson Comorbidity Index (CCI). Bootstrap methods provided standard errors. Endpoints were postoperative stay (LOS), chest tube duration, complications, and lymph node retrieval.ResultsWe analyzed 136 consecutive lobectomy patients. Operative mortality was 1/62 (1.6%) for THOR and 1/74 (1.4%) for VATS, P = 1.00. 5/74 (6.7%) VATS were converted to open procedures. Adjusted median LOS was 7 days (THOR) versus 4 days (VATS), P < 0.0001, HR = 0.33. Adjusted median chest tube duration (days) was 5 (THOR) versus 3 (VATS), P < 0.0001, HR = 0.42. Complication rates were 39% (THOR) versus 34% (VATS), P = 0.61. Adjusted mean number of lymph nodes dissected per patient was 18.1 (THOR) versus 14.8 (VATS), p = 0.17.ConclusionsAfter balancing covariates that affect morbidity, mortality and LOS in this case-control series using propensity-weighting, the results confirm that VATS lobectomy is associated with a statistically significant shorter LOS, similar mortality and complication rates and similar rates of lymph node removal in patients with clinical stage I NSCLC.

Is Intravenous Patient Controlled Analgesia Enough for Pain Control in Patients Who Underwent Thoracoscopy?

This prospective randomized study was conducted to evaluate the efficacy of two common analgesic techniques, thoracic epidural patient-controlled analgesia (Epidural PCA), and intravenous patient-controlled analgesia (IV PCA), in patients undergoing lobectomy by the video-assisted thoracic surgical (VATS) approach. Fifty-two patients scheduled for VATS lobectomy were randomly allocated into two groups: an Epidural PCA group receiving an epidural infusion of ropivacaine 0.2%+fentanyl 5 µg/mL combination at a rate of 4 mL/hr, and an IV PCA group receiving an intravenous infusion of ketorolac 0.2 mg/kg+fentanyl 15 µg/mL combination at a rate of 1 mL/hr. Pain scores were then recorded using the visual analogue scale at rest and during motion (VAS-R and VAS-M, 0-10) for five days following surgery. In addition, we measured the daily morphine consumption, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), satisfaction score, and the incidence of side effects. Thirty-seven patients out of 52 completed the study (18 in the Epidural PCA group, 19 in the IV PCA group). There were no differences in the pain scores, analgesic requirements, pulmonary function, satisfaction score, and the incidence of side effects between groups. This indicates that IV PCA and Epidural PCA are equally effective to control the postoperative pain after VATS lobectomy, which suggests that IV PCA may be used instead of Epidural PCA.

Novel Retractor for Lymph Node Dissection by Video-Assisted Thoracic Surgery

In nonrandomized studies, the video-assisted thoracic surgical (VATS) lobectomy seems to be a safe and effective procedure for treatment of lung cancer. However, there are some difficulties in VATS complete mediastinal lymph node dissection. The presence of the lymph node deep in the mediastinal space necessitates retraction of the surrounding organs. Therefore, we developed a retractor to create enough working space during the VATS procedure. To dissect lymph nodes, we use endoscopic bipolar forceps. These instruments are connected to a special electrosurgical generator to apply bipolar soft coagulation, which enables simultaneous dissection and sealing. Thus, "en bloc" lymph node dissection can be performed during the VATS procedure.

Recurrent hamartoma at the trocar incision site after video-assisted thoracic surgical resection

T he most common benign tumor of the lung is the hamartoma representing 77%. Hamartomas represent 4% to 8% of all solitary pulmonary nodules, which present themselves as well-circumscribed, asymptomatic coin lesions within the pulmonary parenchyma. Usually they are chondromatous hamartomas consisting of cartilage and are regarded as benign neoplasms derived from the peribronchial mesenchymal tissue. Symptoms such as cough, hemoptysis, or pulmonary infections arise only when the location is endobronchial, which is rare (10%). There is an overall incidental finding in approximately 0.25% of autopsies, and hamartomas are found more frequently in men than in women (2:1). Multiple hamartomas are rare and do not include cartilage but pulmonary muscular or endothelial tissue and are therefore called hemangioleiomyomatous and fibroleiomyomatous hamartomas. In the case of a solitary lesion it is necessary to exclude malignancy. Percutaneous, transthoracic computed tomographyguided needle aspiration biopsy yields diagnosis in 85% of solitary pulmonary coin lesions. The risk of pneumothorax is high, ranging from 20% to 24%. Video-assisted thoracic surgical (VATS) resection offers a safe and 100% sure method to obtain a diagnosis with little discomfort for the patient. Most authors recommend enucleation or tissue-sparing resection of the chondromatous hamartoma. Recurrence after excision is practically unknown.

Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients

Background The treatment of primary spontaneous pneumothorax in young adults has been controversial. Conventional treatment consisting of chest tube thoracostomy may be associated with morbidity at the time of tube insertion, prolonged hospitalization, and interval operation in many patients. As spontaneous pneumothorax in young adults is usually associated with apical blebs, we hypothesized that video-assisted thoracic surgical (VATS) resection of the blebs at the time of the first pneumothorax may be an effective treatment associated with low morbidity and short hospital stays. Methods From July 1992 to February 2001, 156 young adults were treated for spontaneous pneumothorax. Within 12 hours of presentation to the emergency department patients underwent semielective VATS with bleb resection and pleuradesis. During follow-up patients were observed for recurrent pneumothorax. Results There were 69 men (44%) and 87 women (56%). The median age was 19 years old (range 14 to 38 years old). Patients were predominantly tall and thin. Patients were mildly symptomatic at the time of presentation. Apical blebs were seen in all patients and the presence of blebs was confirmed in the pathologic specimen. In 23 patients bleeding was associated with bleb rupture. There were no postoperative air leaks. The mean hospital stay was 2.4 ± 0.5 days. Follow-up ranged from 2 to 96 months (median 62 months). There were no recurrences on the index side. Conclusions VATS resection of apical blebs is associated with low morbidity and short hospitalization and provides an attractive alternative to the conventional treatment of initial tube thoracostomy and possible interval repeat thoracostomy or operation. VATS may be an effective first line treatment for spontaneous pneumothorax in young adults. Due to the pathophysiology of this disease, patients should be closely followed for the occurrence of pneumothorax on the contralateral side.

Giant bullous emphysema resection by VATS. Analysis of laser and stapler techniques.

Advances in video-assisted thoracic surgical (VATS) technique led the authors to reconsider the treatment and thoracoscopic management of patients with giant bullous emphysema (GBE). From January 1993 to December 2001 we treated 40 patients with unilateral GBE: 24 males and 16 females, mean age 51+/-1 years. Thirty patients presented respiratory insufficiency, seven patients a spontaneous pneumothorax and three patients a bullae infection. Excision was performed by using Nd:YAG laser in five patients (12.5%) and stapling device in 35 patients (87.5%). Among the last 35, in 20 patients a partial pleurectomy stripping up to the 5th intercostal space was associated. In 15 patients this technique was modified through the systematic application of polytetrafluoroethylene (PTFE) to reinforce stitches. We experienced one conversion to open thoracotomy owing to haemorrhaging, in one patient who underwent a partial pleurectomy stripping. In the stapler resection patients, with PTFE application, the mean duration of air leaks, for type 1 bullae of Wakabayashi was 2.2+/-1.8 days and, for type 4, 5.9+/-1.4 days; the mean length of hospital stay was 6.1+/-0.5 days. The resection in VATS of giant bullous emphysema by stapling device associated to reinforcement in PTFE reduces duration of air leaks and hospitalisation and improves pulmonary function.

A simple maneuver to detect air leaks on the operating table after needlescopic video-assisted thoracic surgery

J Thorac Cardiovasc Surg 2002;124:1029-30