Bilateral anterior minithoracotomy with video assistance for lung volume reduction surgery and pulmonary metastasectomy.

Incisional access to pulmonary pathology involving both lungs has often involved bilateral standard thoracotomies, median sternotomy, and, recently, sequential lateral video-assisted thoracic surgical approaches. Significant problems are inherent to each of these approaches. We introduce a hybrid technique of bilateral simultaneous minithoracotomy with video assistance as an alternative to these other surgical approaches.

Immediate radiographic assessment following laparoscopic antireflux operations is unnecessary.

BACKGROUND: Laparoscopic antireflux operations (LAP) have become increasingly common for the treatment of gastroesophageal reflux disease (GERD). We sought to determine if routine postoperative barium contrast studies following LAP were clinically efficacious in identifying technical problems and life-threatening complications related to the surgical intervention. METHODS: From January 1996 to December 1997, 112 barium studies were performed following 112 LAP procedures (47 male/65 female patients; mean age, 51 years) (group I). This group was compared to a subsequent cohort of 67 patients who underwent LAP between January 1998 and July 1998 without routine early postoperative barium contrast study (group II). RESULTS: In 111/112 of the barium studies of group I, no radiographic abnormality was identified. The average length of stay (LOS) for these patients was 2.6 days. Routine barium studies were not utilized in group II. The average length of stay for patients in group II was 1.4 days. Twelve group II patients underwent early postoperative barium studies to evaluate suspicious clinical symptoms. None of these 12 postoperative studies identified important problems, nor did they alter the patients' clinical management. However, because of the barium study, their LOS was equivalent to those patients who had undergone routine barium study (2.4 days). There was an increase of $1451.80 in hospital charges in the group of patients who had a barium study, largely as a result of the increased LOS. CONCLUSION: The routine use of these studies results in increased patient charges and a prolongation in the length of hospital stay. Immediate postoperative barium studies following laparoscopic antireflux operations are of little value in determining important postoperative problems among patients undergoing LAO.

Laparoscopic management of giant paraesophageal herniation.

BACKGROUND: Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH). METHODS: Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux. RESULTS: Mean operative time was 202+/-81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients. CONCLUSIONS: Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient's symptoms are equivalent and hospitalization and return to full activity are shorter.

A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections.

BACKGROUND: Prolonged air leak is the major limiting factor in early hospital discharge following pulmonary resection. The purpose of this study was to determine whether the use of bovine pericardial strips as a buttress along the lung staple line would decrease air leaks and hospital stay after lobectomy and segmentectomy. METHODS: This was a multicenter trial consisting of 80 patients undergoing pulmonary resection, randomly assigned to the control group (40 patients) or treatment group (40 patients). The treatment group had reinforcement with bovine pericardium. RESULTS: No statistical differences were noted in the mean intensive care unit length of stay (p = 0.9), number of days with a chest tube (p = 0.6), or total length of stay (p = 0.24). Increased air leak duration was associated with assignment to the control group (r = 0.27, p = 0.02). The mean duration of air leak was 2 days and the mean time to chest tube removal was 5.9 days in patients with a buttressed staple line compared to 3 days and 6.3 days, respectively, for patients with nonbuttressed staple lines. CONCLUSIONS: Within the data of this study, no statistical differences were noted between buttressed and nonbuttressed patients. However, the trend toward shortened air leak time and tube removal time was apparent in the buttressed group. With greater number of patients studied, it is likely that the cost of bovine pericardium would be justified by shorter air leak duration and hospitalization.

Vascular endothelial growth factor expression in stage I non-small cell lung cancer correlates with neoangiogenesis and a poor prognosis.

BACKGROUND: Vascular endothelial growth factor (VEGF) plays an important role in tumor growth and metastasis. We investigated the prognostic significance of VEGF overexpression, intratumoral microvessel density (MVD), and angiolymphatic invasion in stage Ia-b non-small cell lung cancer (NSCLC). METHODS: Eighty-five patients undergoing complete surgical resection of pathologic stage Ia-b NSCLC were evaluated. The mean and median clinical follow-up were 37.1 and 39.0 months (range, 30-44 months), respectively. Paraffin-embedded tumor specimens were stained with VEGF and CD31 (a specific endothelial marker) using immunohistochemical methods. VEGF staining was evaluated, by combining both percentage of positive tumor cells and staining intensity, as low (negative and < 20% of tumor cells showing weak positivity), or high (> 20% of tumor cells showing strong positivity). CD31 staining was expressed as MVD per high power field at 400x magnification. Angiolymphatic invasion was expressed as either presence or absence. RESULTS: Low VEGF expression was seen in 25 (29%) patients, and high VEGF expression was seen in 60 (71%) patients. The survival rate in patients with low VEGF expression was significantly higher (80%) than that in those with high VEGF expression (48%, P = .018). The mean MVD in the low VEGF group was 23.7 +/- 5.7 vs. 34.4 +/- 9.3 in the high VEGF group (P = .001). Patients with high MVD also had a significantly lower survival rate than did those with low MVD count (46% vs. 73%, P = .0053). Age, sex, tumor type, and tumor differentiation were not found to be associated with overall survival. The presence of angiolymphatic invasion and T2 stage (i.e., tumor size > 3 cm) were associated with decreased survival. High VEGF expression, tumor size, and angiolymphatic invasion emerged as three independent factors predicting worsening prognosis using multivariate analysis. CONCLUSION: High VEGF expression within stage I NSCLC is closely associated with high intratumoral angiogenesis and poor prognosis. Immunohistochemical evaluation of T stage and VEGF expression along with examination of angiolymphatic invasion perioperatively may aid in predicting prognosis. Adjuvant therapies aimed at retarding tumor angiogenesis may be considered for stage I NSCLC patients with high VEGF levels.

Reoperative laparoscopic antireflux surgery.

BACKGROUND: Laparoscopic antireflux surgery (LAP) is becoming increasingly used for the surgical treatment of medical recalcitrant gastroesophageal reflux disease (GERD). We sought to determine the utility of remedial LAP approaches to antireflux surgery. METHODS: From March 1996 to December 1998, 15 patients underwent remedial LAP to manage medically recalcitrant recurrent GERD after LAP (n = 8) or open antireflux procedure (n = 1) and/or troublesome postfundoplication complications (dysphagia 6, gas bloat 4). The remedial LAP surgery consisted of conversion from Nissen to Toupet fundoplication to manage dysphagia or gas bloat symptoms (n = 7), revision of IAP Nissen fundoplication (n = 7) and LAP revision of a failed open Nissen fundoplication (n = 1) for recurrent reflux. RESULTS: The remedial LAP repair was accomplished in all patients. Findings at operation included disrupted fundoplication (n = 6), incomplete or inappropriately positioned fundoplication (n = 2), paraesophageal hernia (n = 3), or a normal total fundoplication among patients with primary dysphagia (n = 4). Follow-up symptom scoring beyond 3 months of remedial surgery demonstrated a change from the preoperative mean dysphagia, heartburn, gas bloat, and regurgitation score (P < .05). Follow-up GERD testing (manometry, upper gastrointestinal tract, pH testing) was normal in 13 of the 15 patients. CONCLUSIONS: Reoperative antireflux surgery can be accomplished using LAP approaches without compromise of therapeutic intent or increased surgical morbidity. Surgeons sufficiently experienced with these LAP repairs may consider repeat LAP instead of open surgery for patients with recurrent GERD or postfundoplication problems.

Success of laparoscopic fundoplication for gastroesophageal reflux disease.

BACKGROUND: We explored the efficacy of laparoscopic fundoplication (LF) in patients with uncomplicated, medically recalcitrant pathologic gastroesophageal reflux disease (GERD) for whom we previously would have recommended open surgical repair. METHODS: From January 1994 to January 1998, we performed LF on 150 patients (80 men and 70 women) with GERD recalcitrant to maximal medical therapy. No patient suffered from esophageal stricture or epithelial dysplasia; however 16% (24 of 150) had benign Barrett's mucosa. Preoperative esophageal manometry and 24-hour pH testing were obtained in 93% (139 of 150) and 89% (134 of 150) of patients, respectively. Nissen LF (n = 123), Toupet LF (n = 26), or Dor LF (n = 1) were accomplished over a large (54 F) intraesophageal bougie. Preoperative (1 month) and postoperative (>6 month) symptom scoring were assessed on a 0 to 10 scale. Thirty-eight patients with a greater than 6-month postoperative period had manometry and pH studies performed. RESULTS: The laparoscopic approach was successful in 99% (148 of 150) of patients, and there has been no mortality. Operative time was 160+/-59 minutes. Open conversion was required for 2 patients: because of difficulty with dissection owing to adhesions in 1 case and due to perforation in another. Reoperation was required for 5 patients (1 paraesophageal, 2 dysphagia, 2 recurrent reflux). Major postoperative complications involved stroke and pancreatitis in 1 patient each. Mean hospital stay was 2.6+/-1.2 days, full activity resumed by 7 days. Postoperative esophageal pH testing among 38 patients tested more than 6 months after operation demonstrated normal esophageal acid exposure in all but 2. GERD symptoms were relieved at 1 month, 6 months, and after 1 year in 95% (128 of 135), 94% (99 of 105), and 93% (65 of 70) of patients, respectively. CONCLUSIONS: Intermediate-term results with LF suggest this to be a reasonable approach to surgical management of medically recalcitrant uncomplicated GERD. Thoracic surgeons interested in GERD should become familiar with minimally invasive surgical approaches.