[85 consecutive VATS non-rib spread simultaneously stapled lobectomies for malignancy]. / Videoassistierte simultane Stapler Lobektomie (VASSL) beim Bronchialkarzinom.

A new technique for pulmonary lobectomy has been utilized for malignant lesions. Eighty-five consecutive patients with pulmonary neoplasms underwent a VATS non-rib spread Simultaneously Stapled Lobectomy. There were 34 males and 51 females with 61 adeno, 21 squamous, 2 large cell and 1 carcinoid tumor who underwent 18 left upper, 13 left lower, 20 right upper, 7 right middle and 27 right lower lobectomies. Forty-one mediastinoscopies were negative. Patients with positive mediastinoscopies were not selected for curative resection. At VATS exploration, 10 patients had positive nodes. All resected nodes were negative in the other patients. Every bronchoscopy was negative. Operating times averaged 84.5 minutes. No patient received a transfusion. Lesions ranged from 1 cm to 8 cms with an average size of 3.62 cms. Post-operative length of stay averaged 3.38 days. There was no surgical mortality, no hemorrhage, no transfusion and no conversion to an open case in the entire series. No bronchial, vascular or broncho vascular fistula occurred. Complications were minor from which all patients recovered completely. Survival seems similar to patients resected by traditional open techniques.

One hundred video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading.

BACKGROUND: This study was performed to evaluate and determine the validity and benefits of video-assisted thoracic surgical simultaneously stapled pulmonary lobectomy without rib spreading. METHODS: Between September 1992 and August 1995, 100 consecutive video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading were performed. RESULTS: Forty-five male and 55 female patients had 24 right upper, 8 right middle, 29 right lower, 24 left upper, 15 left lower lobectomies for 66 adenocarcinomas, 20 squamous cell carcinomas, 4 large cell carcinomas, 8 benign lesions, and 2 metastatic lesions. Seventy-six patients had negative nodes. Nine patients had positive nodes. Every bronchoscopy was visually and cytologically negative. Forty-nine cervical mediastinoscopies were negative. Operating time for the series averaged 90.3 minutes. Hospitalization averaged 3.5 days for the entire group, but was 2.6 days for the last 20 patients. Lesions ranged from 1.5 to 8 cm, averaging 3.4 cm. There was no surgical mortality, no hemorrhage, no transfusion, and no urgent conversion to an open procedure. No bronchial fistula, vascular fistula, or bronchovascular fistula has occurred. Complications included 6 air leaks, 2 cerebrovascular accidents, 1 infected chest tube site, 2 cases of pneumonitis, and 1 subcutaneous emphysema. CONCLUSIONS: Video-assisted thoracic surgical simultaneously stapled lobectomy without rib spreading is a safe operation that can be combined with lymph node sampling. At this early stage, therapeutic outcomes (survival) for resected neoplasms appear similar to results obtained from traditional open techniques.

Does VATS favor seeding of carcinoma of the lung more than a conventional operation?

Seeding of carcinoma has always been of concern to surgeons. Recent reports have focused on possible implantation of tumor in the small wounds of minimally invasive procedures, i.e. VATS. A patient is presented who had a conventional open lobectomy for carcinoma and later developed tumor in the traditional thoracotomy wound. Although seeding or tumor implantation is accepted by thoracic surgeons, the exact mechanism of tumor implantation has never been scientifically explained or documented. Possibly, a rare and necessary pattern of genetic mutations could be responsible for this infrequent but serious problem.

VATS-Argon Beam Coagulator treatment of diffuse end-stage bilateral bullous disease of the lung.

Diffuse bullous disease of the lungs remains an unrelentless, debilitating, terminal disease. Intensive medical therapy can give transient relief of symptoms. Thoracotomy and resection has not always been successful and can be associated with an increased mortality and morbidity. Eight patients with end-stage bullous disease, unresponsive to medical therapy and not considered to be candidates for a thoracotomy, underwent unilateral video-assisted thoracic surgical ablation of bullae using the Argon Beam Coagulator. Six men and 2 women ranging in age from 28 to 71 years reported a decrease in dyspnea. Three patients restudied had an increase in forced expiratory volume in 1 second of 34%. Postoperatively, 7 patients had an air leak, pneumonia developed in 2 patients, and 3 patients had massive subcutaneous emphysema after parietal pleurectomy. Hospitalization averaged 13.6 days. All patients made a complete recovery, and each was subjectively improved. Steroid use decreased, oxygen requirements decreased, dyspneic episodes decreased, infections decreased, and endurance increased. In 3 patients with a limited follow-up evaluated postoperatively, video-assisted thoracic surgery and the Argon Beam Coagulator seemed to be beneficial for treating advanced, generalized bullous disease.

Endobag.

A simple method for placing specimens in a protective bag during video-assisted thoracic surgery has been developed. The equipment is readily available, and the technique is easy to perform.

Video-assisted thoracic surgical resection of malignant lung tumors.

Forty patients with malignant pulmonary disease underwent evaluation, staging, and a biopsy or resection by means of video-assisted thoracic surgery. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three a lobectomy for primary carcinoma, six exploration of the thorax, five biopsy of the aortopulmonary window, and eighteen a sublobar resection for primary carcinoma of the lung. There was no mortality. Three patients had air leaks that lasted an average of 8 days. Video-assisted thoracic surgery seems to be useful for more precise staging of carcinoma of the lung, and, in some patients, resectional operations can be performed.

One hundred consecutive patients undergoing video-assisted thoracic operations.

Video-assisted thoracic surgery is a new modality that allows visualization of and access to the intrathoracic organs without making a thoracotomy incision. One hundred consecutive patients underwent 113 thoracic procedures using this technique. Eight wedge resections for metastatic lesions, 6 pericardial windows, 1 bronchogenic cystectomy, 4 explorations of the aortopulmonary window, 1 decortication, 5 pleural scleroses, 8 bullous ablations, 25 lung biopsies, 19 wedge resections for carcinoma, 9 explorations of the thorax, 3 lobectomies, 1 esophageal cystectomy, 14 wedge resections for benign lesions, 4 pleurectomies, 1 excision of a neurogenic tumor, 3 mediastinal explorations, and 1 imaged axillary dissection were performed. There was no mortality. Ten patients had complications from which they recovered completely. Patients undergoing video-assisted thoracic operations seem to have reduced postoperative pain, shorter hospitalization, and quicker recovery times. Currently, this new modality appears to have beneficial value for patients; however, only further experience will determine its true merits.

Imaged thoracoscopic lung biopsy.

Imaged thoracoscopic surgery is a technique utilized to operate on the intrathoracic organs without making a formal thoracotomy incision. Eleven patients underwent lung biopsy with this procedure and each had markedly reduced postoperative pain. Each patient resumed preoperative activity levels within one week of discharge from the hospital. Besides thoracotomy and thoracoscopy, imaged thoracoscopic surgery provides another option for approaching the intrathoracic organs.

Imaged thoracic lobectomy: should it be done?

Imaged thoracic surgery is a new modality that is rapidly gaining acceptance from thoracic surgeons. Procedures that traditionally required a thoracotomy can now be done successfully using this technique in some patients. Three patients with primary carcinoma of the lung have undergone lobectomy using imaged thoracic surgery.

Imaged thoracoscopic surgery: a new thoracic technique for resection of mediastinal cysts.

Previously, intrathoracic organs have been approached by either thoracotomy or thoracoscopy. A technique, imaged thoracoscopic surgery, using video optics and projection of images on a screen provides another option for the thoracic surgeon. Two patients with mediastinal cysts, one bronchogenic and one esophageal, underwent surgical removal using imaged thoracoscopic surgery. Postoperative pain was markedly reduced, hospitalization shortened, and recovery accelerated. Numerous complex surgical procedures can be performed using imaged thoracoscopic surgery.

Special report: video-endoscopic thoracic surgery.

Since the advent of video optics, with the projection of images on a screen, a new option has been added to the armamentarium of the thoracic surgeon: video-endoscopic thoracic surgery. A case report of a 33-year-old woman demonstrates the successful new procedure.

Reversible total esophageal exclusion.

A 23-year-old man with miliary tuberculosis had severe esophageal hemorrhage secondary to eroding tuberculous nodes. Balloon tamponade and packing with gauze did not alter the profuse bleeding. Empyema of the right thorax, massive mediastinal nodes, an unknown site of bleeding in the esophagus, and diffuse pulmonary involvement with tuberculosis precluded a thoracotomy. Because of widespread peritoneal tuberculosis, permanent esophageal exclusion by ligation was rejected as bowel interposition would have been extremely difficult at a later time. Reversible total esophageal exclusion was successfully utilized.

Urinary catabolites of ribonucleic acid as cancer markers: a preliminary report of their use in patients with lung cancer.

Rats with aflatoxin-B1-induced hepatomas and dimethylnitrosamine-induced nephroblastomas excreted greater than normal amounts of urinary modified nucleosides and bases, catabolites of ribonucleic acid (RNA). Although both neoplasms caused increased excretions of the same catabolites, their quantitative profiles differed, suggesting that it may be possible to distinguish between tumors. Rats with transplanted tumors (e.g., hepatomas and osteogenic sarcomas) did not excrete elevated levels of urinary RNA catabolites until approximately 20 days after transplantation despite rapid growth of the tumor for the first 15 days. These data suggest that the source of the elevated levels of these excretory products may be the host's tissue RNA. Preliminary studies in human beings with lung cancer showed marked elevation of one or more urinary RNA catabolites. Resection of the diseased tissue in 2 patients caused a drop in levels. The measurement of urinary RNA catabolites may be useful in the diagnosis, prognosis, and evaluation of therapy in patients with lung cancer.

Repeat mediastinoscopy.

Although it has been maintained that a repeat mediastinoscopy results in high morbidity and mortality, it was considered an essential staging procedure in this group of 12 patients. The results of repeat mediastinoscopy were negative in 10 patients and positive in 2. On the basis of negative findings, 6 patients underwent thoracotomy. Five of them had a possible curative resection, and the remaining patient had an unresectable invasive carcinoma. An unnecessary thoracotomy was avoided in 2 patients with positive mediastinal nodes. For various reasons, thoracotomy was not indicated in the other 4 patients. In the evaluation of a patient with a new or recurrent pulmonary lesion, repeat mediastinoscopy can be performed safely. When findings are negative, it would appear to increase the likelihood of a curative resection, whereas when findings are positive, an unnecessary thoracotomy can be avoided.

Mediastinoscopy in advanced superior vena cava obstruction.

Superior vena cava syndrome can be a rapidly progressive, lethal process that is caused by a malignancy in 92 to 94% of cases. Since all effective therapy is inherently harmful, it would be reassuring to have a definitive tissue diagnosis before initiating treatment. Because easily accessible tissue is not always available, mediastinoscopy must be relied on to confirm the diagnosis in some patients. Twenty-nine patients with advanced superior vena cava syndrome were reviewed. Fifteen of them required mediastinoscopy to confirm the diagnosis, since lesser procedures, i.e., bronchoscopy, needle biopsy, and sputum cytology, were negative for malignant tissue. Contrary to reports in the literature, mediastinoscopy can be performed safely in patients with advanced superior vena cava syndrome and can yield a definitive diagnosis in each.