Video-assisted thoracoscopic surgery for spontaneous pneumothorax--a 7-year learning experience.
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OBJECTIVES: To determine the effect of increasing experience of video-assisted thoracoscopic surgery (VATS) in the treatment of spontaneous pneumothorax (SP) on clinical efficacy and surgical practice. PATIENTS AND METHODS: A prospective study of 180 consecutive operations in 173 patients who underwent VATS for SP by a single surgeon during a 7 year period. RESULTS: 118 patients, mean age 32.1 years (range 13-63 years), were treated for primary spontaneous pneumothorax (PSP) while 55 patients, mean age 65.9 years (range 28-92 years), were treated for secondary spontaneous pneumothorax (SSP). All patients had VAT parietal pleurectomy combined in 162 (90%) patients with stapled bullectomy. At a current median experience of 2.0 years (range 0.4-6.8 years), 12 (6.6%) patients required reoperation for treatment failures within 12 months of surgery--9 patients within 30 days of VATS and 3 for late recurrent pneumothorax. Two patients (both with SSP) died within 30 days of surgery. When compared with PSP, VATS in SSP is characterized by an elderly, male predominance, a longer postoperative stay, a higher mortality rate and a lower rate of late recurrence. With increasing experience of the technique, there has been a significant decrease in treatment failures. In the treatment of PSP, both operating time and postoperative stay have decreased significantly with experience whilst the use of staple cartridges per patient has increased significantly with experience in both PSP and SSP. CONCLUSION: There is a demonstrable 'learning curve' effect on the clinical efficacy and surgical practice of video assisted thoracoscopic surgery for spontaneous pneumothorax. (+info)
Chylothorax after myocardial revascularization with the left internal thoracic artery.
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A 38-year-old male underwent coronary artery bypass grafting (CABG). A saphenous vein graft was attached to the left marginal branch. The left internal thoracic artery was anastomosed to the left anterior descending artery (LAD). The early recovery was uneventful and the patient was discharged on the 5th postoperative day. After three months, he came back to the hospital complaining of weight loss, weakness, and dyspnea on mild exertion. Chest X-rays showed left pleural effusion. On physical examination, a decreased vesicular murmur was detected. After six days, the diagnosis of chylothorax was made after a milky fluid was detected in the plural cavity and total pulmonary expansion did not occur. On the next day, both anterior and posterior pleural drainage were performed by videothoracoscopy, and prolonged parenteral nutrition (PPN) was instituted for ten days. After seven days the patient was put on a low-fat diet for 8 days. The fluid accumulation ceased, the drains were removed and the patient was discharged with normal pulmonary expansion. (+info)
Current opinions and practices in the treatment of spontaneous pneumothorax.
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The approach to the initial management of spontaneous pneumothorax differs markedly from centre to centre, and it is difficult in practice to establish a standard protocol. This article reviews the concepts behind the British Thoracic Society guidelines, and reports the varying opinions and alternative practices existing currently. There is a need for more evidence-based studies to identify what is the best approach. Based on a review of relevant recent reports, the author attempts to work out an unbiased practical approach that can be used safely and that can possibly give the best overall cost effective results. (+info)
Thoracoscopic removal of intrathoracic neurogenic tumors: a combined Chinese experience.
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OBJECTIVE: To review the surgical and clinical results of minimally invasive resection of intrathoracic neurogenic tumors using a video-assisted thoracoscopic technique. SUMMARY BACKGROUND DATA: Thoracoscopy has emerged as a possible means for diagnosing and managing various intrathoracic disorders. Benign intrathoracic tumors often are ideal lesions for resection using a video-assisted technique. The authors report on their combined experience with the thoracoscopic resection of 143 intrathoracic neurogenic tumors. METHODS: Between March 1992 and February 1999, 143 patients with intrathoracic neurogenic tumors were diagnosed and underwent resection using video-assisted thoracoscopic techniques in three teaching centers. Case selection, surgical technique, and clinical results were reviewed. RESULTS: The average age of the patients was 40.8 years; 57.3% were male. Thirty-eight patients (27%) had symptoms attributable to the masses. Seventy-two masses were neurofibromas, 33 were neurilemmomas, 7 were paragangliomas, and 31 were ganglioneuromas. All but seven tumors were located in the posterior mediastinum. The masses were on average 3.5 cm in greatest diameter. The mean surgical time was 40 minutes, and the average hospital stay was 4.1 days. There were no major postoperative complications or recurrences to date. Nine patients reported paresthesias over the chest wall during a mean follow-up of 29 months. CONCLUSIONS: Resection of intrathoracic neurogenic tumors using a thoracoscopic technique based on standard surgical indications would seem to be appropriate. Most of these masses are benign and readily removed. For dumbbell tumors, a combined thoracic and neurosurgical approach is mandatory. (+info)
The effect of lung biopsy on lung function in diffuse lung disease.
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The aim of this study was to investigate the effect on lung function of lung biopsy used in the diagnosis of diffuse lung disease carried out by an open procedure or by video-assisted thoracoscopy. One hundred and sixteen patients with diffuse lung disease who attended the Royal Brompton Hospital were studied retrospectively. Thirty five patients underwent open lung biopsy, and 33 video-assisted thoracoscopic biopsy and 48 had their diagnosis made without biopsy. All patients underwent lung function tests before and after surgery, or at an interval of 3-6 months in those who did not undergo biopsy. No significant differences were found in changes in lung function between those who had and had not undergone biopsy, and the proportions of patients whose lung function improved or deteriorated were similar. Lung biopsy by an open procedure or by video-assisted thoracoscopy did not differ in its effects on lung function. The results for older patients, those with severe disease and those with fibrosing alveolitis were the same as for the whole group. Open lung biopsy for the diagnosis of diffuse lung disease does not deleteriously affect lung function whether carried out by an open or a minimally invasive procedure. (+info)
Early experience of video-assisted thoracoscopic surgery.
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Consecutive 25 patients (M/F:18/7) underwent video-assisted thoracoscopic surgery (VATS) for various chest illnesses. These included nine cases of pneumothorax, three cases of pericardial effusion, three cases of pleural effusion, four cases of lung lesion requiring either incisional or excisional biopsy, two cases of empyema, one case of traumatic haemothorax, and three cases of mediastinal lesion. The mean age was 36.2 years (range 19-78 years). A total of forty-three procedures were performed. The mean durations of intrapleural chest-tube requirement and hospitalisation following VATS alone were 4.5 days (range: 0-13 days) and 8.3 days (range: 2-25 days) respectively. No intraoperative complication and VATS procedure-related mortality reported. Apart from simple analgesics such as paracetamol or tramadolol, no opiate analgesia was given to patients undergoing only VATS. The results support that VATS is a safe and effective procedure in the management of pulmonary, mediastinal, pericardial and pleural diseases and the treatment of persistent and recurrent spontaneous pneumothorax. (+info)
Video assisted thoracoscopic bullectomy and acromycin pleurodesis: an effective treatment for spontaneous pneumothorax.
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The introduction of video assisted thoracoscopic surgery (VATS) has led to the development of several endoscopic options for the management of spontaneous pneumothorax. We describe here our experience in the management of primary spontaneous pneumothorax (SP). We carried out 58 VATS procedures on 55 patients during the period 1993-95. There were six conversions to open thoracotomy because of dense adhesions in five patients and a large apical bulla of 20 cm in one. These patients were excluded from the study. The remaining 49 patients underwent 52 VATS procedures. There were 37 males and 12 females with a median age of 23 (range: 15-71) years. The indications for surgery were persistent SP for more than 5 days in 21 (40%), and recurrent SP in 31 (60%). Twenty-six procedures (25 patients) consisted of bullectomy alone (group 1; 1/1/93-30/9/94) and the next 26 procedures (24 patients) included chemical pleurodesis with 2 g of Acromycin (Lederle) in 10 ml of 0.9 normal saline (group 2; 1/10/94-31/12/95). Both groups had a mean follow up of 38 months (range: 36-40). Mean postoperative chest drainage in group 2 (3.1 +/- 1.09) was significantly shorter than in group 1 (4.7 +/- 1.0). Group 2 patients also had a shorter hospital stay (4.8 /- 1.08 vs. 6.76 +/- 1.09). There were five (20%) recurrences in group 1 while only one (4%) occurred in group 2. In view of these results we recommend the routine use of Acromycin pleurodesis in addition to thoracoscopic bullectomy. (+info)
Surgical strategy of complex empyema thoracis.
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BACKGROUND: The optimal treatment of empyema thoracis has been widely debated. Proponents of pleural drainage alone, drainage plus fibrinolytic therapy, video-assisted thoracoscopic surgical (VATS) debridement, and open thoracotomy each champion the efficacy of their approach. METHODS: This study examines treatment of complex empyema thoracis between June 1, 1994, and April 30, 1997. Twenty-one men and 9 women underwent 30 drainage/decortication procedures (14 open thoracotomies and 16 VATS) in treatment of their disease. Effusion etiology was distributed as follows: infectious-14; neoplastic-associated-7; traumatic-3; other-6. RESULTS: The mean preoperative hospital stay was 14 +/- 8.8 days, (11.4 +/- 6.5 days for VATS vs 16.8 +/- 10.2 days for thoracotomy). Hospital stay from operation to discharge for thoracotomy patients was 10.0 -/+ 7.2 days (median 8.5 days) and for VATS patients 17.6 -/+ 16.8 days (median 11 days). These differences were not statistically significant. Duration of postoperative thoracostomy tube drainage was 8.3 -/+ 4.6 days for thoracotomy patients and 4.7 -/+ 2.8 days in the VATS group (p = 0.01). Operative time for the thoracotomy group was 125.0 -/+ 71.7 minutes, while the VATS group time was only 76.2 -/+ 30.7 minutes. Estimated blood loss for the thoracotomy group was 313.9 -/+ 254.0 milliliters and for the VATS group 131.6 -/+ 77.3 milliliters. Three of the 30 patients (10.0%) required prolonged ventilator support (>24 hours). Morbidity included one diaphragmatic laceration (VATS group) and one thoracic duct laceration (thoracotomy). Two VATS procedures (6.7%) required conversion to open thoracotomy for thorough decortication. CONCLUSIONS: The surgical approach to empyema thoracis is evolving. In the absence of comorbid factors, the significantly lower requirement for chest tube drainage time in the VATS patients suggests that this modality is an attractive alternative to thoracotomy in the treatment of complex empyema thoracis. (+info)