Lung T-cell subset composition at the time of surgical resection is a prognostic indicator in non-small cell lung cancer.

NSCLC arises in the complex environment of chronic inflammation. Depending on lung immune polarization, infiltrating immune cells may either promote or suppress tumor growth. Despite the importance of the immune microenvironment, current staging techniques for NSCLC do not take into consideration the immune milieu in which the neoplasms arise. T-cell subset content was compared between paired tumor-bearing and contralateral lungs, patient and control peripheral blood. The relationship between T-cell subset distribution and survival were evaluated. CD4 and CD8+ T cells were subsetted by CD45RA/CD27 and analyzed for expression of activation, adhesion, and homing markers. Strikingly, T-cell content was indistinguishable between lungs. Compared with peripheral blood, naïve CD4 and CD8 T cells were rare in BAL. CD4+ BAL T cells showed increased CD95 (higher apoptotic potential) and CD103 expression (epithelial adhesion), but decreased CD38 (activation) and CCR7 expression (lymph node homing). CD8+ BAL T cells showed increased CD103 expression and decreased CD28 expression (co-stimulation). Differences in CD28, CD95, and CCR7 expression were more pronounced within memory cells, while differences in CD4+ CD103 expression were more prominent in effector/memory cells. Of these populations, the absence of lung CD4 T cells with an effector-like phenotype (CD45RA+/CD27-) emerged as a predictor of favorable outcome. Patients with a low proportion (≤0.44%) had 90% 5-year survival (n = 10, median survival 2,343 days), compared with 0% (n = 9, median survival 516 days) of patients with a higher proportion. Further study is required to confirm this association prospectively and define the function of this subpopulation.

Endoluminal management of bronchogenic carcinoma in 2010: diagnosis, staging, and therapy.

Endoluminal bronchogenic carcinoma, though a minority of lung cancer cases, presents a unique opportunity to utilize techniques for the diagnosis and therapy that are unavailable for more peripheral tumors. This review explores current techniques for the diagnosis, staging, and therapy of endoluminal central bronchogenic tumors and also introduces techniques currently under investigation as potential improvements or replacements for current techniques using recent literature. Additionally, the new staging criteria set forth in the 7th edition of the TMN staging system as a result of the American Joint Committee on Cancer (AJCC), International Union Against Cancer (IUCC), and the International Association for the Study of Lung Cancer (IASLC) are discussed with respect to endoluminal bronchogenic carcinoma.

An increased proportion of inflammatory cells express tumor necrosis factor alpha in idiopathic achalasia of the esophagus.

Achalasia is a motility disorder characterized by the absence of coordinated peristalsis and incomplete relaxation of the lower esophageal sphincter. The etiology remains unclear although dense inflammatory infiltrates within the myenteric plexus have been described. The nature of these infiltrating cells is unknown. The aim of this study was to evaluate the expression of proinflammatory cytokines - namely, tumor necrosis factor alpha and interleukin-2 - in the distal esophageal muscle in patients with achalasia. Lower esophageal sphincter muscle from eight patients undergoing myotomy or esophagectomy for achalasia of the esophagus were obtained at the time of surgery. Control specimens consisted of similar muscle taken from eight patients undergoing operation for cancer or Barrett's esophagus. The expression of tumor necrosis factor alpha and interleukin-2 were assessed by immunohistochemistry. The total number of inflammatory cells within the myenteric plexus were counted in five high power fields. The percentage of infiltrating cells expressing tumor necrosis factor alpha or interleukin-2 was calculated. Clinical data including demographics, preoperative lower esophageal sphincter pressure, duration of symptoms, and dysphagia score (1 = no dysphagia to 5 = dysphagia to saliva) were obtained through electronic medical records. Statistical comparisons between the groups were made using the unpaired t-test, Fisher's exact test, or Mann-Whitney U test, with a two-tailed P-value less than 0.05 being considered significant. The total number of inflammatory cells was found to be similar between the groups. A significantly higher proportion of inflammatory cells expressed tumor necrosis factor alpha in achalasia as compared with controls (22 vs. 11%; P= 0.02). A similar percentage of infiltrating cells expressed interleukin-2 (40 vs. 41%; P= 0.87). Age, gender, preoperative lower esophageal sphincter pressure, or dysphagia score were not correlated to expression of these cytokines. There was, however, a significant inverse correlation between duration of symptoms and the proportion of inflammatory cells expressing tumor necrosis factor alpha in achalasia (P= 0.007). In conclusion, a higher proportion of infiltrating inflammatory cells expressed tumor necrosis factor alpha in achalasia. Furthermore, this proportion appears to be highest early in the disease process. Further studies are required to more clearly delineate the role of tumor necrosis factor alpha in the pathogenesis of this idiopathic disease.

A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy.

OBJECTIVE: Esophagectomy may lead to impairment in gastric emptying, unless a pyloroplasty or pyloromyotomy is performed. These procedures may be technically challenging during minimally invasive esophagectomy, and they are associated with a small but definable morbidity, such as leakage and dumping syndrome. We sought to determine the results of our early experience with injecting the pylorus with botulinum toxin instead of conventional pyloric drainage. METHODS: Fifteen patients who had undergone esophagectomy and injection of the pylorus with botulinum toxin were identified. Twelve patients had undergone botulinum toxin injection at the time of minimally invasive esophagectomy, and the remaining three had been treated endoscopically after surgery. The latter three patients had undergone esophagectomy with either no pyloric drainage (n = 2) or an inadequate pyloromyotomy (n = 1), and they presented in the postoperative period with delayed gastric emptying. The adequacy of emptying after injection was assessed by the patients' ability to tolerate a regular diet, a barium swallow, and a nuclear gastric emptying study. RESULTS: No patient injected with botulinum toxin during esophagectomy developed delayed gastric emptying or aspiration pneumonia in the perioperative period. Eight of these patients underwent a nuclear emptying scan at a median of 4.2 months after surgery, which showed a mean emptying half-life of 100 min. With a median follow-up of 5.3 months, one patient (8%) required reintervention for symptoms of gastric stasis, presumably after the effect of the toxin subsided. All three patients injected postoperatively demonstrated an improvement in symptoms of gastric outlet obstruction and were able to resume a regular diet. CONCLUSIONS: Injection of the pylorus with botulinum toxin can be performed safely in patients undergoing esophagectomy. Longer-term studies are needed to clarify the efficacy and durability of this technique compared to the accepted procedures of pyloromyotomy or pyloroplasty.

Association of immunoreactive hepatocyte growth factor with poor survival in resectable non-small cell lung cancer.

We have shown previously that hepatocyte growth factor (HGF), which is produced by lung fibroblasts, is a potent mitogen and motogen for both normal and neoplastic bronchial epithelium, and that expression of the HGF receptor, the c-met proto-oncogene protein, is uniformly found in the human bronchial epithelium and in non-small cell lung carcinomas (NSCLCs; P. Singh-Kaw et al., Am. J. Physiol., 268: L1012-L1020, 1995). Yamashita et al. have reported an association of HGF with poor survival in invasive ductal carcinoma of the breast (Cancer Res., 54: 1630-1633, 1994). There are few prognostic markers for lung cancer, and the high recurrence rate for stage I lung cancer suggests the frequent presence of undetectable tumor burden in such patients. Criteria are needed to evaluate these patients for risk of recurrence. We have now evaluated whether HGF present in resectable lung tumors has prognostic significance. In this study, 56 primary NSCLCs, mainly adenocarcinomas, were examined for presence of HGF by quantitative Western blot. These tumors consisted of tissue from 34 stage I patients, 9 stage II patients, and 13 stage IIIa patients who underwent curative resection for primary NSCLC. Extracts of whole tumor tissue were analyzed after separation of proteins by electrophoresis and transfer of proteins to nitrocellulose membranes. Immunoreactive (ir)-HGF was visualized by reaction with a polyclonal anti-HGF antiserum and quantitated by densitometry. Lung tumor content of ir-HGF varied widely among individuals. Median ir-HGF content in tumor extracts was 15.3 ng/40 microg of tumor protein; mean ir-HGF was 27.2 ng/40 microg of tumor protein. The median and mean ir-HGF were both significantly higher in tumor tissue from patients who suffered a recurrence during the follow-up period compared with those with no evidence or residual disease; this was true of all patients (P = 0.0001) and stage I patients analyzed separately (P = 0.002). Analysis of survival curves indicated that ir-HGF levels higher than the median were associated with poor overall survival (P < 0.03). Univariate analysis showed three factors related to poor overall survival in this set of patients: ir-HGF, tumor (T) status (a measure of primary tumor size and extent), and age. Nodal (N) status and stage were only marginally related to overall survival, most likely because the majority of the patients in the study were stage I. N status, stage, and T status were related to disease-free survival, however. Multivariate Cox analysis showed that ir-HGF, T status, and age independently had a negative impact on overall survival. ir-HGF was a strong independent negative prognostic indicator (P = 0.0001) with a relative risk of 1.022 per unit of ir-HGF (ng/40 microg of protein). This demonstrates that, in this group of patients, the relative risk of ir-HGF content increased continuously as ir-HGF increased, and exceeded 10 at units of ir-HGF of 100 or more. In comparison, in this group of patients, the relative risk of a T status greater than 1 was 4.75 and that of age greater than 65 was 3.95. The combined negative effect of a T status greater than 1 and elevated ir-HGF on survival was also highly pronounced (P < 0.005). In addition, elevated ir-HGF had a negative impact on survival when patients were stratified by stage or N status. Stage I patients with high ir-HGF values had a worse outcome than stage II or stage IIIa patients with low ir-HGF values. Elevated ir-HGF was strongly associated with poor outcome for resectable NSCLC patients as a group, and also identified stage I patients with poor outcome, indicating that it could be a useful indicator of risk of relapse and death in patients who have early lung cancer. The impact of elevated ir-HGF was especially prominent in patients whose T status was greater than 1, suggesting that patients with both risk factors who are stag

Variation of p53 mutational spectra between carcinoma of the upper and lower respiratory tract.

Mutations of the p53 tumor suppressor gene are the most common genetic alterations associated with human cancer. Tumor-associated p53 mutations often show characteristic tissue-specific profiles which may infer environmentally induced mutational mechanisms. The p53 mutational frequency and spectrum were determined for 95 carcinomas of the upper and lower respiratory tract (32 lung and 63 upper respiratory tract). Mutations were identified at a frequency of 30% in upper respiratory tract (URT) tumors and 31% in lung tumors. All 29 identified mutations were single-base substitutions. Comparison of the frequency of specific base substitutions between lung and URT showed a striking difference. Transitions occurred at a frequency of 68% in URT, but only 30% in lung. Mutations involving G:C-->A:T transitions, which are commonly reported in gastric and esophageal tumors, were the most frequently identified alteration in URT (11/19). Mutations involving G:C-->T:A transversions, which were relatively common in lung tumors (3/10) and are representative of tobacco smoke-induced mutations were rare in URT tumors (1/19). Interestingly, G:C-->A:T mutations at CpG sites, which are characteristic of endogenous processes, were observed frequently in URT tumors (9/19) but only rarely in lung tumors (1/10), suggesting that both endogenous and exogenous factors are responsible for the observed differences in mutational spectra between the upper and lower respiratory systems.

Detection of K-ras mutations in lung carcinomas: relationship to prognosis.

The K-ras mutation is one of the most common genetic alterations found in human lung cancer. To evaluate the prognostic value of ras gene alterations in lung cancer in a U.S. population, we have screened 173 human lung tumors, which included 127 adenocarcinomas, 37 squamous carcinomas, and 9 adenosquamous carcinomas, for mutations in the K-ras gene using the combination of the PCR and denaturing gradient gel electrophoresis. Forty-three tumors contained K-ras mutations. Of these, 41 were identified among the adenocarcinomas (32%), 1 among the squamous carcinomas (2.7%), and 1 among the adenosquamous carcinomas (11%). Forty of these mutations were found in codon 12 and consisted of 24 G to T transversions, 12 G to A transitions, 2 G to C transversions, and 1 double GG to TT mutation. Two other G to T transversions were found in codon 13, and 1 A to C transversion was found in codon 61. The data showed that gender did not seem to affect the incidence and the types of the K-ras mutations or amino acid changes. Examination of the mutations in adenocarcinomas in relation to overall survival showed no difference in adenocarcinomas with K-ras mutations compared with K-ras-negative adenocarcinomas. However, the substitution of the wild-type GGT (glycine) at codon 12 with a GTT (valine) or a CGT (arginine) showed a strong trend (P = 0.07) toward a poorer prognosis compared with wild-type or other amino acid substitutions. Substitution of the wild-type glycine for aspartate (GAT) showed a strong trend (P = 0.06) for a better outcome than the valine or arginine substitution. Although these trends will require larger patient populations for verification, these data suggest that the prognostic significance of K-ras mutations may depend on the amino acid substitution in the p21(ras) protein.

Extracellular matrix expression in metastasizing and nonmetastasizing adenocarcinomas of the lung.

Alterations in extracellular matrix, cell-cell and cell-matrix adhesion, and oncogenes are thought to be important in tumor progression and metastasis. Adenocarcinomas of the lung from 31 patients were studied for immunohistochemical expression of basement membrane molecule type IV collagen, type IV collagenase, and integrins alpha2,3,v adhesion molecules to assess their diagnostic and prognostic importance in pathological stage T2 tumors. The results indicate that with decreasing tumor differentiation, there is a progressive loss of type IV basement membrane collagen (P = .06) and decreased integrin alpha2 expression (P = .03). Type IV collagenase expression was significantly associated with the presence of lymph node metastases, with moderate to strong expression present in 53% T2N1 tumors compared with none (0%) of the T2N0 tumors (P = .008). Integrin alpha(v) was increased in tumors with nodal metastases compared with those without (P = .08). Loss of alpha2 and alpha3 integrins was associated with increased alpha v expression (P = .03). Median survival was 48 months for T2N0 and 20 months for T2N1 (P = .07). In correlating expression of the immunohistochemical markers and survival, type IV collagenase expression was found to be a predictor of survival at a level of P = .07. Measurable alterations in integrins and extracellular matrix, and in particular, expression of matrix-degrading enzyme type IV collagenase may be of prognostic importance in resectable adenocarcinoma of the lung.

Techniques for localization of pulmonary nodules for thoracoscopic resection.

Significant advances in surgical equipment, video monitoring, and endoscopic surgical techniques have expanded the role of thoracoscopy to include pulmonary resection. One limitation of the thoracoscopic technique is the loss of manual palpation to identify the nodule that is either too small or too deep beneath the pleural surface. We describe the techniques used in 300 thoracoscopic pulmonary resections that have aided in identification of pulmonary nodules. These techniques include careful preoperative assessment of the computed tomogram, preoperative injection of methylene blue, or a needle localizing system to identify the nodule. Intraoperative techniques include instrument palpation, digital palpation, and intraoperative ultrasonography. It should be possible to identify the majority of pulmonary nodules at the time of thoracoscopy with these localizing techniques. All nodules were successfully identified in our last 200 thoracoscopic resections.

Thoracoscopic resection of pulmonary metastases.

OBJECTIVE: To describe the use of thoracoscopic techniques to achieve parenchymal sparing wedge resection of peripheral lung lesions in patients with a history of malignancy, and to describe the morbidity, mortality, and hospital course associated with this approach. DESIGN: Case series. SETTING: University hospital. PARTICIPANTS: Patients with a history of malignancy and lesions on computerized tomography in the outer one third of the lung parenchyma. MAIN OUTCOME MEASUREMENTS: Histologic analysis of resected lung lesions, operative findings, operative time, duration of chest tube drainage and hospital stay, operative morbidity, and mortality. RESULTS: Twenty-one thoracoscopic resections of pulmonary parenchymal lesions were performed on 15 patients. All peripheral lesions identified by computerized tomography were found at thoracoscopy and successfully resected with the Nd:YAG laser (n = 7), an endoscopic stapler (n = 10), or both (n = 4). The mean diameter of the lesions was 0.8 cm (range 0.2 to 1.5 cm). Histologic analysis revealed metastatic disease in 13 patients and benign disease in 2 patients. All resection margins were free of tumor. The mean duration of chest tube drainage and postoperative hospital stay were 1.8 +/- 0.1 and 3.3 +/- 0.1 days, respectively. Mean operative time was 111 min (range 45 to 155 min). One patient who underwent a right thoracoscopic resection developed a transient left vocal cord paresis. There were no other complications and no deaths. CONCLUSION: Thoracoscopy was successful in identifying peripheral lung lesions and allowed for parenchymal sparing resection identical in extent to that performed with open approaches. For select patients with peripheral lung nodules felt to be metastases, thoracoscopic resection may result in reduced morbidity, cost, hospital stay and allow for more rapid institution of therapy for the primary disease.

Thoracoscopic resection of a posterior mediastinal neurogenic tumor.

Advances in endoscopic instrumentation and a growing enthusiasm for minimally invasive surgical techniques have sparked renewed interest in therapeutic thoracoscopy. We report the successful thoracoscopic resection of a posterior mediastinal nerve sheath tumor. A 35-year-old asymptomatic woman was found to have a posterior mediastinal mass on chest roentgenogram. Computed tomography and magnetic resonance imaging confirmed the presence of the lesion and showed no evidence of intraspinal extension. Exploratory thoracoscopy revealed a localized lesion without intraspinal extension. Thoracoscopic resection of the lesion was then performed. The patient's postoperative course was uncomplicated and she was discharged on the fifth postoperative day. The therapeutic potential of thoracoscopy continues to be realized as experience with the technique grows.

Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular "blow holes".

Four patients who recently developed massive spontaneous subcutaneous emphysema in our intensive care unit are reported. No obviously remediable intrathoracic process was found in any of these patients. The acute physiologic impairment and grotesque cosmetic deformity were immediately alleviated by making bilateral 3-cm infraclavicular incisions down to the pectoralis fascia. These acutely decompressed the progressive subcutaneous dissection and each patient's subcutaneous emphysema resolved without any additional invasive therapy.

Video-assisted thoracoscopic surgery for resection of lung metastases.

Resection of indeterminate pulmonary lesions in patients with a history of malignancy is indicated, as the presence of metastases will provide prognostic information and often dictate further therapy. Pulmonary metastasectomy also improves survival in select patients with favorable tumor histologies. We reported the results of video-assisted thoracoscopic surgery (VATS) resection of indeterminate lung nodules in 72 patients with a history of malignancy. All lesions identified on preoperative high-resolution CT scan were found at surgery with visual inspection, digital palpation, or (in 13 cases) CT-guided needle localization. All lesions were resected nonanatomically with a rim of normal parenchyma, as is done with open techniques; 63 patients were found to have metastases and 9 patients had benign disease. There was no mortality, minimal morbidity, and decreased hospital stays in patients undergoing VATS resection compared with historical control subjects. These data and other reports have led to the widespread use of VATS for patients undergoing resection to establish a diagnosis. The role of VATS in patients with favorable tumor histology and limited tumor burden for whom metastasectomy may result in a survival advantage remains controversial. Improved image resolution with spiral CT scans and digital palpation, combined with intraoperative ultrasound examination of the lung, may decrease or eliminate the number of lesions missed with a VATS approach. The role of therapeutic VATS metastasectomy remains to be defined. Thus, this procedure currently should be used only in clinical trials.

Video thoracoscopic management of benign and malignant pericardial effusions.

Surgical management of symptomatic benign and malignant effusive pericarditis is often required. Twenty-two patients with medically recalcitrant effusive, nonconstrictive pericarditis underwent pericardial resection by a video-assisted thoracoscopic surgical (VATS) technique (9 malignant, 13 benign). Pericardiectomy, resulting in complete drainage of the pericardial space and control of patient symptoms was accomplished routinely. Ipsilateral pleural effusions, originally present in 11 patients, were also managed. The VATS pericardiectomy was well tolerated even by gravely ill patients. This approach should be considered as an alternative to lateral thoracotomy or subxiphoid pericardial window for the surgical management of patients with symptomatic benign and malignant pericardial effusions.

Thoracoscopy for empyema and hemothorax.

Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage +/- decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 +/- 2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4 +/- 7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8 +/- 0.5 days postoperatively and hospital stay averaged 4.3 +/- 1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.

Management of an extensive tracheoesophageal fistula by cervical esophageal exclusion.

Giant tracheoesophageal fistulae occurring in ventilator-dependent patients usually result in significant ventilatory embarrassment. Cervical exclusion of the fistula can safely control the fistula and quickly restore adequate ventilation to these critically ill patients.

Thoracoscopic Nd:YAG laser resection of a solitary pulmonary nodule.

Advances in endoscopic surgical techniques and laser technology have expanded the role of thoracoscopy. We report a thoracoscopic resection of a benign pulmonary lesion. A 44-year-old man underwent a successful Nd:YAG laser-assisted thoracoscopic resection of a peripheral lung hamartoma. The patient's postoperative course was uncomplicated. Thoracotomy with its attendant morbidity was avoided. Continued success with thoracoscopic resection will have a significant impact on the management of select patients with peripheral, solitary pulmonary nodules.

Experience with the Sarns centrifugal pump in postcardiotomy ventricular failure.

The reported clinical use of the Sarns centrifugal pump (Sarns, Inc./3M, Ann Arbor, Mich.) as a cardiac assist device for postcardiotomy ventricular failure is limited. During a 25-month period ending November 1988, we used 40 Sarns centrifugal pumps as univentricular or biventricular cardiac assist devices in 27 patients who could not be weaned from cardiopulmonary bypass despite maximal pharmacologic and intraaortic balloon support. Eighteen men and nine women with a mean age of 60.4 years (28 to 83) required assistance. Left ventricular assist alone was used in 12 patients, right ventricular assist in 2, and biventricular assist in 13. The duration of assist ranged from 2 to 434 hours (median 45). Centrifugal assist was successful in weaning 100% of the patients. Ten of 27 patients (37%) improved hemodynamically, allowing removal of the device(s), and 5 of 27 (18.5%) survived hospitalization. Survival of patients requiring left ventricular assist only was 33.3% (4/12). Complications were common and included renal failure, hemorrhage, coagulopathy, ventricular arrhythmias, sepsis, cerebrovascular accident, and wound infection. During 3560 centrifugal pump hours, no pump thrombosis was observed. The Sarns centrifugal pump is an effective assist device when used to salvage patients who otherwise cannot be weaned from cardiopulmonary bypass. Statistical analysis of preoperative patient characteristics, operative risk factors, and postoperative complications failed to predict which patients would be weaned from cardiac assist or which would survive.

Video-assisted thoracic surgical resection with the neodymium:yttrium-aluminum-garnet laser.

Since January 1991, we have performed 79 video-assisted neodymium: yttrium-aluminum-garnet laser resections for pulmonary nodular or interstitial disease. Pathologic examination demonstrated malignancy in 59 patients (32 primary and 27 metastatic), benign nodules in 11, interstitial processes in seven, and granulomatous disease in two. There were 39 men and 40 women with a mean age of 63.4 +/- 12.5 years. Thirty-nine patients underwent resection with the neodymium:yttrium-aluminum-garnet laser alone and 40 had lesions resected with a combination of laser and endoscopic stapling. Laser excision was performed for lesions deep in the substance of the lung or on its effaced surface; both are locations that make stapling alone difficult. Fifteen of 32 patients with a diagnosis of primary lung malignancy underwent open anatomic resections. Pulmonary reserves of the other 17 patients were inadequate for further resection. Operative time, duration of chest tube placement, length of hospital stay, and complication rate were compared with those for 72 patients undergoing video-assisted thoracic surgical resection of nodules with staplers alone. Although operative time for laser-assisted procedures was longer (p < 0.05), there were no differences in duration of chest tube placement or hospital stay compared with stapled resections. The complication rate for laser-treated cases was not higher than for stapled resections and consisted primarily of air leaks lasting 2 to 7 days. The neodymium:yttrium-aluminum-garnet laser is a safe and precise primary or adjunctive tool for video-assisted thoracic surgical pulmonary resection.

Lobectomy--video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial.

Video-assisted thoracic surgery has been adopted by some thoracic surgeons as the preferred approach over thoracotomy for many benign and malignant diseases of the chest. However, little concrete evidence exists to support this technique as the superior approach. This randomized study was carried out to define the advantages of video-assisted lobectomy over muscle-sparing thoracotomy and lobectomy. Sixty-one patients with presumed clinical stage I non-small-cell lung cancer were entered into the study. Each patient was randomized to muscle-sparing thoracotomy and lobectomy or video-assisted lobectomy. Six patients were excluded from the study either because final pathologic results revealed nonmalignant disease (3 patients) or because an attempted video-assisted lobectomy was converted to a thoracotomy. This left 30 patients in the thoracotomy group and 25 patients in the video-assisted group. No significant differences existed between the two groups in operating time, intraoperative blood loss, duration of chest tube drainage, or length of hospital stay. Significantly more postoperative complications occurred in the thoracotomy group (p < 0.5), the majority of which were prolonged air leaks. Return to work time was not an issue because the majority of the patients were either retired or not working at the time of the operation. Only three patients had persistent postthoracotomy pain (thoracotomy, n = 2; video-assisted lobectomy, n = 1). We conclude that video-assisted lobectomy was not associated with a significant decrease in duration of chest tube drainage, length of hospital stay, postthoracotomy pain, or, in this group of patients, a faster recovery time and return to work. Video-assisted lobectomy continues to expose the patient to the risk of a major pulmonary resection being done in an essentially closed chest. These results illustrate the need for critical evaluation of video-assisted thoracic surgery before the procedure is accepted as a superior approach based on presumed and thus far unproved advantages.