VATS Plication of the Diaphragm: A Descriptive Observational 10-Year Southampton Experience.

OBJECTIVE: The aim of the study was to report the safety and efficacy of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2006 and 2016. METHODS: Adult patients selected on etiology and combination of investigations including plain chest x-ray, computed tomography of chest and abdomen, lung functions in supine and sitting positions, radiological/ultrasonic screening for diaphragmatic movement, and phrenic nerve conduction studies. We incorporated a triportal VATS and Endostitch device for plication, using CO2 insufflation to maximum 12 mm Hg. Bilateral simultaneous plication and high-risk patients were electively admitted to intensive therapy unit postoperatively. RESULTS: Thirty-five patients (24 males) had their diaphragm plicated. The mean age was 56.6 years (range = 23-76 years). The mean body mass index was 32.1 (range = 22.2-45.4). Twenty one were right, 13 left, 2 patients had VATS simultaneous bilateral plication, and 1 had sequential VATS bilateral plication. Paralysis was idiopathic in 17, posttraumatic in 5, postremoval of mediastinal tumor in 4, and postcardiac surgery in 3. All patients presented with lifestyle-limiting dyspnea and orthopnea, three were on nocturnal noninvasive ventilation. Five were diabetic and 16 were smokers. The mean supine forced expiratory volume in the first second was 62.5% of predicted. Twenty two were performed by VATS (63%), three converted to thoracotomy, and 13 were open limited thoracotomy (historic). The mean hospital stay was 4.5 days (range = 1-18, mode 2 days). Intensive therapy unit admission was required in six patients for mechanical ventilation 0 to 3 days. Five patients (14%) had no improvement in symptoms. There were no deaths, no 30-day readmissions, and no long-term neuralgia in this series. CONCLUSIONS: We found minimal access VATS plication of the diaphragm to be feasible and safe, but no firm conclusions should be drawn from our limited resources. We report the feasibility of concomitant bilateral VATS plication of the diaphragm in two adults, and this was not previously reported in the adult population. There is a need for further good quality, prospective studies, and randomized controlled studies evaluating efficacy of VATS diaphragmatic plication.

Intravascular papillary endothelial hyperplasia (Masson's hemangioma) presenting as a soft-tissue sarcoma.

Intravascular papillary endothelial hyperplasia (Masson's hemangioma) is an unusual benign, non-neoplastic, vascular lesion characterized histologically by papillary fronds lined by proliferating endothelium. It may appear as a primary or pure form developing in a distended vessel, or it can be associated with hemangiomas, pyogenic granulomas, or lymphagiomas. Nearly all lesions are intimately associated with a thrombus in various stages of organization. The main significance of intravascular papillary endothelial hyperplasia is its clinical and histological resemblance to soft-tissue sarcoma and possible misinterpretation as such. A case of intravascular papillary endothelial hyperplasia clinically diagnosed and treated as a low-grade angiosarcoma, in a 60-year-old man, presenting with a mass in the left thigh, is reported.