Peri-operative management of patients for video assisted thoracoscopic thymectomy in myasthenia gravis.
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Three patients of myasthenia gravis, who under went video-assisted thoracoscopic surgery (VATS) were given general anaesthesia by propofol infusion and muscle relaxation by atracurium infusion. Isoflurane was added to control depth of anaesthesia on the basis of haemodynamic changes during surgery. One lung ventilation (OLV) was achieved by placement of Carlens left sided double lumen bronchocatheter. Right-sided surgical approach was used to perform thymectomy. Contrary to claimed short duration of surgery, in first patient, OLV lasted for 10 hours 30 minutes and patient developed re-expansion pulmonary oedema. OLV in second and third patient was for six hours thirty minutes and three hours 45 minutes respectively. Morning dose of pyridostigmine was omitted and atracurium (0.1 mg/kg) was found to be satisfactory for intubation and relaxation was maintained with atracurium infusion to get desired monitored effect. We could not extubate our patients due to longer duration of surgery and the sequelae there off. Post-operative elective ventilation and spontaneous weaning off the atracurium effect was thus preferred. (+info)
Thoracoscopic electrode implantation for diaphragm pacing in dogs.
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BACKGROUND: Diaphragm pacing is an attractive method of ventilatory support; however, it requires electrode implantation to the phrenic nerve or diaphragm. The thoracic approach is favored for several reasons, and it usually accompanies invasive bilateral thoracotomy. OBJECTIVES: This study was conducted to develop a new electrode suitable for video-assisted thoracoscopic implantation, which is less invasive than the conventional thoracic approach. METHODS: The feasibility of video-assisted thoracoscopic implantation was tested with newly designed electrodes using 5 mongrel dogs. Furthermore, diaphragm pacing was performed for 60 min to test whether or not the implanted electrodes were functional. RESULTS: Video-assisted electrode implantation was successful in all 5 cases. No complications occurred during the implantation procedure. In acute-phase pacing trials, the electrodes stimulated the phrenic nerves for 60 min without any pacing failures. The mean value of PaCO(2) increased gradually from 32.2 +/- (SEM) 1.52 to 54.6 +/- 4.58 mm Hg, and the value of tidal volume decreased gradually from 242.9 +/- 31.3 to 147.5 +/- 24.5 ml in 60 min pacing. CONCLUSIONS: The thoracoscopic implantation of new electrodes was less invasive, and was a safe procedure for diaphragm pacing. Meticulous care should be taken to avoid muscle fatigue. (+info)
Surgical sympathectomy for reflex sympathetic dystrophy syndromes.
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PURPOSE: The purpose of this study was the assessment of the efficacy of thoracoscopic cervicodorsal and open lumbar sympathectomy for the reduction of pain severity and disability associated with reflex sympathetic dystrophy (RSD). METHODS: From 1992 to 2000, 73 patients with RSD underwent 46 video-assisted thoracoscopic (first to fourth thoracic ganglion) or 37 surgical lumbar (first to fourth lumbar ganglion) sympathetic chain resections. The patients were referred from multidisciplinary pain clinics with documented sympathetically maintained pain syndrome on the basis of reproducible more than 50% reduction in pain severity score (0, no pain; 10, most severe pain imaginable) for more than 2 days after sympathetic block therapy. The mean duration of the RSD symptoms before sympathectomy was 26 plus minus 14 months (range, 6 to 100 months). Postoperative pain severity score, limb disability, and overall patient satisfaction were assessed by an independent third-party observer at a mean follow-up period of 30 months. RESULTS: No operative mortality or serious morbidity (Horner's syndrome, bleeding that needed transfusion, wound infection) occurred. Transient (<3-month) postprocedural sympathalgia developed in one third of the patients for cervicodorsal sympathectomy and 20% of the patients for lumbar sympathectomy and was treated effectively with trigger point/proximal ganglion block therapy or transcutaneous electrical nerve stimulation. At 3 months after sympathectomy, 10% of the patients had conditions that were judged treatment failures with no reduction in pain severity or limb disability. The remaining patients testified to more than 50% pain reduction, with pain severity scores decreasing from a mean of 8.7 before surgery to 3.4 after sympathectomy. At 1 year, one quarter of the patients had continued significant pain relief (pain severity score, <3) and an additional 50% of the patients indicated continued but reduced pain severity and an increase in daily/work activities. Overall, patient satisfaction (willingness to have procedure again, benefit from sympathectomy) was 77% and was not significantly influenced by patient age, RSD duration/stage, or extremity involvement (lumbar, 84%; cervicodorsal, 72%). CONCLUSION: Patients with RSD with a confirmed sympathetically maintained pain syndrome can realize long-term benefit from surgical sympathectomy. Procedural efficacy was similar for both upper limb and lower limb RSD syndromes, although the level of pain reduction did deteriorate with time. After sympathectomy, the patients with RSD had a low incidence rate (7%) of "new" complex regional pain or disabling compensatory sweating syndromes. (+info)
Reasons for the delays in the definitive diagnosis of lung cancer for more than one year from the recognition of abnormal chest shadows.
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OBJECTIVE: Primary lung cancer generally has a poor prognosis if not diagnosed at an early stage. But some lung cancers grow very slowly. In particular, adenocarcinoma is sometimes observed for years with no change of tumor size. In this study, we examined the reasons for the delays in reaching a definitive diagnosis of lung cancer. METHODS: We retrospectively reviewed primary lung cancer cases between January 1995 and December 1999 and examined those whose definitive diagnoses were delayed for more than a year. RESULTS: A total of 222 primary lung cancers were diagnosed. Of those, 19 patients (group A, 8.6%) were diagnosed after more than a year, and the other 203 (group B, 91.4%) were diagnosed within one year. The proportion of women in group A was significantly higher than that in group B (p<0.05). The mean age of group A was significantly younger than that of group B (p<0.05). The Brinkman Index of group A was significantly lower than that of group B (p<0.05). The histologic types were significantly different between the two groups (p<0.05). In group A, 18 patients (94.7%) had adenocarcinomas. Five primary reasons for the delays in group A were identified: 1) Four patients were tentatively diagnosed as inflammation or benign tumor on CT and were consequently not followed-up. 2) The chest CT shadows in 6 patients were suspected lung cancers but transbronchial lung biopsy findings did not show malignancy. 3) Four patients were tentatively diagnosed as inflammation or benign tumor on CT, but the tumors showed only very slow growth or no change at all. 4) The chest CT shadows of 2 patients were suspected lung cancer, but the patients refused to undergo video-assisted thoracic surgery (VATS) or closer examination. 5) Three patients did not consult medical facilities for a second examination. CONCLUSIONS: Many of the adenocarcinomas reviewed in our study grew slowly or remained unchanged for years. Doctors are mainly responsible for the delays in the definitive diagnosis and should aggressively perform VATS or closer examinations without hesitation. (+info)
A case of primary leiomyosarcoma of the chest wall successfully resected under the video-assisted thoracoscopic approach.
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We report a case of a 62-year-old woman with primary leiomyosarcoma of the chest wall which was successfully resected under the video-assisted thoracoscopic approach. The disease was found during the treatment for a malignant melanoma of the left heel. On the preoperative CT images, the lesion was suspected to be a metastasis of the malignant melanoma. The thoracoscopic surgery revealed that the tumor originated from the parietal pleura, and it was resected with a 5-mm margin of normal pleura. Histopathologically, the tumor was diagnosed as low-grade leiomyosarcoma. Since no residual tumor cells were proven in the resected margins histologically, further resection was not performed. At present, she is alive and well with no sign of recurrence of leiomyosarcoma two years and one month after operation. Thoracoscopic surgery is worth trying for accurate diagnosis of and effective treatment for a chest lesion without apparent invasion of the chest wall on the preoperative CT images. (+info)
Optimal strategy for the first episode of primary spontaneous pneumothorax in young men. A decision analysis.
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OBJECTIVE: Primary spontaneous pneumothorax (PSP) is not uncommon in young men and is associated with frequent recurrence. The frequent recurrence after conservative treatment and resultant anxiety for recurrence are sources of disability. We explored which procedure is more appropriate as the initial therapy in terms of quality-adjusted life expectancy (QALE). DESIGN: Decision analysis using a Markov model. DATA SOURCES: Structured literature review for clinical probability. Utility derived from patients and medical staff using time trade-off method. SETTING: Hypothetical cohort. PATIENTS: Twenty-year-old men with a first episode of PSP for which simple aspiration was ineffective. INTERVENTIONS: One of the following treatment options: 1) thoracoscopic surgery, 2) pleural drainage followed by thoracoscopic surgery for recurrence, 3) pleural drainage followed by thoracoscopic surgery for the second recurrence, 4) pleurodesis followed by thoracoscopic surgery for recurrence, 5) pleurodesis followed by thoracoscopic surgery for the second recurrence, 6) pleural drainage followed by pleurodesis for the first recurrence and thoracoscopic surgery for the second recurrence. MEASUREMENTS AND MAIN RESULTS: During the 1-year period after one of the initial treatments, the QALE was 9.49 months for thoracoscopic surgery, 9.47 for pleurodesis, and 7.80-7.99 for pleural drainage. The QALE for thoracoscopic surgery was the longest among the 6 strategies during the period from 5 to 24 months. None of the variables in sensitivity analyses altered the main results except for thoracoscopic surgical death rate. When it exceeds 0.3%, pleurodesis becomes the preferred strategy. CONCLUSION: On the basis of the current best available data and patients' preference, thoracoscopic surgery can be considered the treatment of choice for the first episode of PSP. (+info)
Pulmonary MALT lymphoma with amyloid production in a patient with primary Sjogren's syndrome.
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A 53-year-old woman was admitted to our hospital complaining of cough, low grade fever, chest pain and sicca symptoms. A chest radiograph showed an abnormal shadow and chest computed tomography revealed a tumor in left S6. She was diagnosed as Sjogren's syndrome by sialography and histological findings of labial biopsy. The surgically resected tumor specimen showed proliferation of lymphoid cells with lymphoepithelial lesions, which were positive for CD20 and kappa light chain. Kappa light chain-positive amyloid was found within the tumor. The tumor showed rearranged kappa light chain genes. The diagnosis was pulmonary mucosa associated lymphoid tissue lymphoma with amyloid production. (+info)
Thoracoscopic treatment of Bochdalek hernia in the adult: report of a case.
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Bochdalek hernia is a type of congenital diaphragmatic hernia that mainly occurs in childhood, but is extremely rare in adults. A case report of Bochdalek hernia in a 17-year-old woman, complaining of left lateral upper abdominal pain is herein reported with a brief review of the literature. The herniated organs into the thoracic cavity in this case were the as stomach, large intestine, spleen and greater omentum which was diagnosed using computed tomography, an upper gastrointestinal double contrast study and irrigography. The patient was successfully treated by video-assisted thorachoscopic surgery (VATS) with a pushback method. The post-operating course was uneventful with minimal pain of the surgical wound. This case demonstrated the efficacy of the VATS repair for Bochdalek hernia. (+info)