Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery: A Single-Center Experience

BACKGROUND: We report our surgical technique for nonintubated uniportal video-assisted thoracoscopic surgery (VATS) pulmonary resection and early postoperative outcomes at a single center. METHODS: Between January and July 2017, 40 consecutive patients underwent nonintubated uniportal VATS pulmonary resection. Multilevel intercostal nerve block was performed using local anesthesia in all patients, and an intrathoracic vagal blockade was performed in 35 patients (87.5%). RESULTS: Twenty-nine procedures (72.5%) were performed in patients with lung cancer (21 lobectomies, 6 segmentectomies, and 2 wedge resections), and 11 (27.5%) in patients with pulmonary metastases, benign lung disease, or pleural disease. The mean anesthesia time was 166.8 minutes, and the mean operative duration was 125.9 minutes. The mean postoperative chest tube duration was 3.2 days, and the mean hospital stay was 5.8 days. There were 3 conversions (7.5%) to intubation due to intraoperative hypoxemia and 1 conversion (2.5%) to multiportal VATS due to injury of the segmental artery. There were 7 complications (17.5%), including 3 cases of prolonged air leak, 2 cases of chylothorax, 1 case of pleural effusion, and 1 case of pneumonia. There was no in-hospital mortality. CONCLUSION: Nonintubated uniportal VATS appears to be a feasible and valid surgical option, depending on the surgeon’s experience, for appropriately selected patients.

Medical Thoracoscopy in Pleural Disease: Experience from a One-Center Study / 결핵및호흡기질환

BACKGROUND: Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia. MT has been performed at the Seoul National University Hospital since February 2014. This paper summarizes the findings and outcomes of MT cases at this hospital. METHODS: Patients who had undergone MT were enrolled in the study. MT was performed by pulmonologists, using both rigid and semi-rigid thoracoscopes. During the procedure, patients were under conscious sedation with fentanyl and midazolam. Medical records were reviewed for clinical data. RESULTS: From February 2014 to January 2016, 50 procedures (47 cases) were performed (diagnostic MT, 26 cases; therapeutic MT, 24 cases). The median age of patients was 66 years (59–73 years), and 38 patients (80.9%) were male. The median procedure duration from initial incision to insertion of the chest tube was 37 minutes. The median doses of fentanyl and midazolam were 50 µg and 5 mg, respectively. All procedures were performed without unexpected events. Of the 26 cases of pleural disease with an unknown cause, 19 were successfully diagnosed using MT. Additionally, diagnostic MT provided clinically useful information in the other six patients. Therapeutic MT was very effective for treatment of malignant pleural effusion or empyema. The median number of days with chest tube drainage was 6 (3 days for diagnostic MT and 8 days for therapeutic MT). CONCLUSION: MT is a useful and necessary procedure for both diagnosis and treatment of pleural diseases.

Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication

BACKGROUND: Surgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy. METHODS: Eleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO₂ gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence. RESULTS: The improvement of forced expiratory volume at 1 second in the group using CO₂ gas and the group not using CO₂ gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO₂) and 15.6±0.89 (without CO₂) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred. CONCLUSION: Thoracoscopic plication under single lung ventilation using CO₂ insufflation could be an effective, safe option to flatten the diaphragm.

Valoración de la digitopresión del cuff externo como método práctico para la determinación del volumen y la presión del globo del tubo endotraqueal / Assessment of acupressure of the outer cuff as a practical method for the determination of the volume and pressure of the endotracheal tube balloon

Introducción: En la anestesia general, la presión que ejerce el manguito del tubo endotraqueal (TET) sobre la mucosa debe mantenerse en un rango de seguridad que evite complicaciones por sobreinflación o desinsuflación. En el hospital Loayza, los instrumentos de medición objetiva del cuff no son de uso común, se usa la digitopresión para este fin. Objetivo: Valorar la digitopresión del cuff externo como método de determinación de presión adecuada del manguito del tubo endotraqueal. Materiales y métodos: Estudio transversal prospectivo observacional. En pacientes intubados, se describió la apreciación de la presión del cuff externo por digitopresión del asistente y residente. Luego se midió la presión del cuff y se corrigió adecuadamente (rango adecuado de presión de 20 a 30 cm H20). Resultados: De los 200 casos, 54.5 por ciento fueron mujeres (39.3+/-13.5 años vs 47.1+/-14 en hombres). Las mujeres tienen menores presiones (38.2 cm H20 versus 48.9 cm H20 en hombres). Los residentes insuflaron el 93 por ciento de casos, lo hicieron adecuadamente solo en 19.9 por ciento versus 55.5 por ciento del asistente. Los residentes apreciaron el cuff adecuadamente en un 15.5 por ciento versus 3.5 por ciento del asistente. Conclusión: el estudio muestra la discordancia entre el método subjetivo y objetivo para determinar si el cuff del TET está adecuadamente inflado. Se sugiere el empleo de métodos más objetivos para su determinación.

Introduction: In general anesthesia, the pressure of the cuff of the endotracheal tube (TET) on the mucosa must be kept in a safe range that avoids complications overinflation or deflation. At the Hospital Loayza, the objective measurement instruments cuff are commonly used acupressure is used for this purpose. Objective: To assess the external cuff acupressure as a method of determining proper pressure of the endotracheal tube cuff. Materials and Methods: Prospective observational cross-sectional study. In intubated patients, described the assessment of external cuff pressure by acupressure and resident assistant. Then measured cuff pressure and corrected properly (proper pressure range 20-30 cm IDO). Results: Of the 200 cases, 54.5 per cent were women (39.3 + /-13.5 years vs 47.1 + /- 14 for men). Women have less pressure (48.9 cm H20 versus 38.2 cm H20 in men). Residents breathed 93 per cent of cases, properly made only in 19.9 per cent versus 55.5 per cent in the wizard. Residents appreciated the cuff properly by 15.5 per cent versus 3.5 per cent in the wizard. Conclusion: The study shows the discrepancy between subjective and objective method to determine if the ETT cuff is properly inflated. It suggests the use of more objective methods for its determination.

Eficacia y eficiencia del tubo bucofaríngeo con succión continua - tubo de Claudet - para mantener el control de la vía aérea durante la rinoplastía con anestesia local bajo sedación / Effectiveness and efficiency of the oropharyngeal tube with continuos suction - Claudet tube - to maintain airway control during rhinoplasty under local anesthesia with sedation

Objetivo: Evaluar la eficacia y eficiencia del tubo bucofaríngeo con succión continua û tubo de Claudet -, para mantener el control de la vía aérea libre durante la rinoplastia con anestesia local bajo sedación. Material y métodos: Se realizó una investigación observacional, prospectiva y analítica. Se valoró la eficacia (saturación de oxígeno, frecuencia de pulso y presencia de cianosis) y la eficiencia (tiempo operatorio, cantidad de sangrado, cambio de taponamiento nasal durante cirugía)m del tubo de Claudet en 39 pacientes operados de rinoplastia con anestesia local bajo sedación moderada a profunda entre 1999 y 2001, comparándose con 39 pacientes de control. Resultados: La eficacia fue del 87.1% en el grupo de estudio (GE) y 51.3% en el grupo control (GC) (p < 0.001), la saturación de oxígeno mayor a 90% fue 87.1% en GE vs. 51.3% en GC (< 0.01), la frecuencia del pulso fue 80-100 latidos/minuto en 89.9% en GE y 41% en GC (p < 0.001) y la ausencia de cianosis distal fue 100% en GE y 12.9% en GC (p < 0.05). El tiempo promedio de cirugía fue 53.8 minutos en GE y 83.7 minutos en GC (p < 0.001), el sangrado 110.8 ml en GE y 138.1 ml en GC (p > 0.05) y se cambió de tapón nasal durante cirugía 1.8 veces en GE y 5.2 en GC (p < 0.001). Se aspiró con el tubo de Claudet un promedio de 36.6 ml de sangre (la tercera parte del sangrado total). Conclusión El tubo de Claudet es eficaz y eficiente para mantener el control de la vía aérea en la rinoplastia con anestesia local bajo sedación moderada a profunda.

Objectives: To evaluate the efficacy and efficiency of the oropharyngeal tube with continuous suction ûClaudet tube - to keep the airway control during rhinoplasty under local anesthesia with sedation. Material and methods: Observational, prospective and analytical study. We evaluated the efficacy (oxygen saturation, pulse rate and presence of cyanosis) and the efficiency (operating time, amount of bleeding, change of nasal packing during surgery) of the Claudet tube in 39 patients undergoing rhinoplasty with local anesthesia under moderate to deep sedation between 1999 and 2001 and compared them with 39 control cases. Results: Efficacy was 87.1% in the study group (SG) and 51.3% in the control group (CG) (p < 0.001), oxygen saturation more than 90% was 87.1% in SG and 51.3% in CG (p < 0.01), pulse rate was 80-100 beat/minute in 89.9% of SG and 41% of CG (p < 0.001), and the absence of distal cyanosis was 100% in SG and 12.9% in CG (p < 0.05). The average time of surgery was 53.8 minutes in SG and 83.7 minutes in CG (p < 0.001), the bleeding was 110.8 ml in SG and 138.1 in CG (p > 0.05), and nasal packing was changed during surgery 1.8 times in SG and 5.2 in CG (p < 0.001). An average of 36.6 ml of blood (a third of the total bleeding) was aspirated with the Claudet tube. Conclusions: The Claudet tube is effective and efficient to keep the airway control in rhinoplasty with local anesthesia under moderate to deep sedation.

Estudo comparativo das técnicas de cinesioterapia respiratória convencional e associado às diagonais de membros superiores na reexpansão torácica em indivíduos adultos jovens / Comparative study of conventional techniques of kinesiotherapy respiratory and associate members of the diagonal in the upper chest reexpansion in adults

Objetivo - A expansibilidade torácica é definida como o movimento observado no tórax durante uma incursão inspiratória e expiratória, este movimento pode facilmente ser alterado após alguns procedimentos cirúrgicos que exijam a presença de drenos torácicos. O objetivo do presente trabalho foi avaliar cirtometria torácica em pacientes com drenos torácicos que realizam fisioterapia convencional ou associadas a diagonais de membros superiores. Método - Os pacientes que possuíam drenos torácicos foram divididos em dois grupos, o grupo controle realizava somente fisioterapia convencional e o grupo tratado realizava fisioterapia convencional associada a diagonais de membros superiores, após a execução dos procedimentos a cirtometria era avaliada em ambos os grupos. Resultados - A expansibilidade obtida após a realização de ambas as técnicas não foram estatisticamente significante em relação às medidas pré-terapêutica. Conclusão - Não houve diferença estatisticamente significante entre os dois métodos realizados para a reexpansão torácica em pacientes com dreno de tórax. Sugere-se que esta pesquisa seja posteriormente estendida para um número maior de sessões, para que possivelmente obtenha uma diferença estatisticamente significante. Recomenda-se também que se realizem trabalhos utilizando outras variáveis tais como força muscular respiratória,volumes e capacidades pulmonares.

Objective - The chest expansion is defined as the movement observed in the chest during an incursion into inspiratory and expiratory, this movement can easily be changed after some surgical procedures that require the presence of chest drains. The objective of this study was to evaluate thoracic expansion in patients with chest tubes or performing physiotherapy associated with the upper diagonal. Method - Patients who had chest tubes were divided into two groups, the control group performed only conventional physiotherapy and treatment group performed physical therapy associated with the upper diagonal, after performing the procedures cirtometry was evaluated in both groups. Results - The expansion obtained after performing both techniques were not statistically significantly higher than the pre-therapy. Conclusion - There was no statistically significant difference between the two methods performed to reexpansion in patients with chest tube. It is suggested that this research is subsequently extended to a larger number of sessions to possibly get a statistically significant difference. It is also recommended that work is carried out using other variables such as respiratory muscle strength, lung volumes and capacities.

Clinical Analysis of Iatrogenic Pneumothorax / 대한흉부외과학회지

BACKGROUND: This study was designed to determine etiologic factors for iatrogenic pneumothorax in an era of increased use of invasive procedures and to evaluate its impact on morbidity. MATERIAL AND METHOD: Subjects were 112 patients (65 men and 47 women ranging in age from 20 to 90 years) who were diagnosed with an iatrogenic pneumothorax between January 2005 and December 2008. We reviewed medical records retrospectively. RESULT: The leading causes of iatrogenic pneumothorax were percutaneous needle aspiration (50), central venous catheterization (29), acupuncture (14), thoracentesis (8) and positive pressure ventilation (7). The majority of the patients (60 of 114) were treated with chest tubes. The mean duration of hospital treatment was 5.8 (+/-4.0) days. Hospitalization was prolonged in 24 patients (21.1%). No patient died from iatrogenic pneumothorax. CONCLUSION: In our study, the most common cause of iatrogenic pneumothorax was percutaneous needle aspiration. The mortality and morbidity from iatrogenic pneumothorax is not significant. The recognition of pneumothorax, depends on careful examination after completion of an invasive procedure, and should be followed by prompt and definitive therapy.

Percutaneous Radiofrequency Ablation of Inoperable Primary Lung Cancer

PURPOSE: To present the initial experience of percutaneous radiofrequency ablation (RFA) of inoperable primary lung cancer, and to assess the technical feasibility and potential complications. MATERIALS AND METHODS: Twenty patients with inoperable lung cancer underwent percutaneous RFA. Nineteen of 20 patients had stage III or IV non-small cell lung cancer, and the remaining one had stage I lung cancer with pulmonary dysfunction. The mean tumor size was 4.6+/-0.4 cm (range, 1.8-8.4 cm). RFA was performed with a single (n=18) or cluster (n=2) cool-tip RF electrode and a generator under CT guidance using local anesthesia and conscious sedation. Twenty tumors were treated in 28 sessions. Patients were assessed by contrast-enhanced CT in all cases at 1 week, 1 month, and 3 months. Eleven patients received chemotherapy (n=10) or radiotherapy (n=1) after RFA. RESULTS: RFA was technically successful and well tolerated in all patients. Complete necrosis was attained in 7 lesions (35%), near complete (90-99%) necrosis in 10 lesions (50%), and partial (50-89%) necrosis in 3 lesions (15%). During the mean follow up of 202 days (21 to 481 days), tumor size was decreased in 13 patients, unchanged in 3, and increased in 4. In the latter four, additional RFA was performed. One patient underwent surgery three months after RFA and the histopathologic findings showed a large cavity with thin fibrotic wall suggestive of complete necrosis. During or after the procedure, pneumothorax (n=10), moderate pain (n=4), blood tinged sputum (n=2), and pneumonia (n=2) were developed. Chest tube drainage was required in only 1 patient due to severe pneumothorax. Other patients were managed conservatively. Seven patients died at 61 to 398 days (mean, 230 days) after RFA. The remaining 13 patients were alive 21 to 481 days (mean, 187 days) after RFA. CONCLUSION: RFA appears to be a technically feasible and relatively safe procedure for the cytoreductive treatment of inoperable, non-small cell lung cancer and warrants further investigation as a complementary treatment to chemotherapy or radiation therapy.

Viscum Album Therapy in Malignant Pleural Effusion / 대한흉부외과학회지

BACKGROUND: Malignant pleural effusion is a common clinical problem in neoplastic patients. With the diagnosis of a malignant pleural effusion, palliative therapy was done. One of the treatments was a chemical pleurodesis. Talc was the most commonly used a sclerosing agent, but the quality of patient's life was not improved. We was evaluated by other agents such as Viscum album for relief of malignant pleural effusion. MATERIAL AND METHOD: From November 2001 to October 2003, 17 patients who underwent to chemical pleurodesis for the malignant pleural effusion. We compared the talc (group I: 10 patients) and Viscum album (group II: 7 patients). We analysed them retrospectively in term of various factors and results. RESULT: There were no significant differences between group I and group II in the sex ratio, mean age, origin of primary cancer and site, but, group I had higher successful rate (80%:71%) than group II. Group II had better length of chest tube stay after procedure, Karnofsky performance and recurrence than group I. The failed treatement group was related to the pleural fluid pH and interval of initial chemical pleurodesis after thoracostomy. CONCLUSION: Although the chemical pleurodesis with Viscum album was slightly lower than talc in the successful rate, there was an alternative method instead of the chemical pleurodesis with talc to improve the patient's quality of life in malignant pleural effusion.

Viscum Album Therapy in Malignant Pleural Effusion / 대한흉부외과학회지

BACKGROUND: Malignant pleural effusion is a common clinical problem in neoplastic patients. With the diagnosis of a malignant pleural effusion, palliative therapy was done. One of the treatments was a chemical pleurodesis. Talc was the most commonly used a sclerosing agent, but the quality of patient's life was not improved. We was evaluated by other agents such as Viscum album for relief of malignant pleural effusion. MATERIAL AND METHOD: From November 2001 to October 2003, 17 patients who underwent to chemical pleurodesis for the malignant pleural effusion. We compared the talc (group I: 10 patients) and Viscum album (group II: 7 patients). We analysed them retrospectively in term of various factors and results. RESULT: There were no significant differences between group I and group II in the sex ratio, mean age, origin of primary cancer and site, but, group I had higher successful rate (80%:71%) than group II. Group II had better length of chest tube stay after procedure, Karnofsky performance and recurrence than group I. The failed treatement group was related to the pleural fluid pH and interval of initial chemical pleurodesis after thoracostomy. CONCLUSION: Although the chemical pleurodesis with Viscum album was slightly lower than talc in the successful rate, there was an alternative method instead of the chemical pleurodesis with talc to improve the patient's quality of life in malignant pleural effusion.

The Effect of Hand Massage on Pain and Anxiety Related to Chest Tube Removal in Patients with a Lobectomy / 기본간호학회지

The main purpose of this study was to identify the effect of hand massage on pain and anxiety related to chest tube removal in patients with a lobectomy. The research design of this study was a nonequivalent control group non-synchronized design. Of the twenty nine adult subjects, fourteen were assigned to the experimental group and fifteen to the control group. The data were obtained over 3 months from a medical center in Seoul. The instruments used to assess trait state anxiety was the Spielberger Trait-State anxiety Inventory. For Pain and psychological anxiety, The Visual Analogue Scale was used. Hiko analogue sphygmo- manometer(2001) was used to check blood pressure and pulse rate as indicators of physiological anxiety. Subjects in the experimental group received hand massage for 5 minutes just before chest tube was removed, and subjects assigned to the control group did not receive hand massage. Data were analysed with x2-test and Mann-Whitney U test using the SPSSWIN 10.0 program. The results of the study are as follows; 1. Hypothesis 1: "there will be a significant difference between two groups in the level of pain after chest tube removal" was supported (u = 23.00, p<0.001). 2. Hypothesis 2: "there will be a significant difference between the two groups in the level of psychological anxiety after chest tube removal" was supported (u = 3.00, p<0.001). 3. Hypothesis 3: "there will be a significant difference between the two groups in physiological anxiety(systolic, diastolic blood pressure and pulse rate) after chest tube removal" was supported(u = 55.50, p = 0.01 ; u = 41.50, p = 0.01 ; u = 20.50, p<0.001, relatively). The findings of this study indicate that hand massage is effective for pain and anxiety related to chest tube removal in patients with lobectomy. Therefore, hand massage is recommended as an effective nursing intervention for relieving pain and anxiety in patients undergoing chest tube removal. Further research is needed to identify the proper duration and timing to achieve the optimal effect of hand massage. A larger subject population is required to apply the current findings to the general population. Further research is also needed to assess the effects of hand massage in other patient subsets. Finally, it would be interesting to see if the effects of hand massaging would be attenuated when performed by a non-medical specialist.

A case of hepatopleural fistula complicated by transcatheter arterial chemoembolization for hepatocellular carcinoma with liver abscess / 대한내과학회지

Pleural complication is extremely rare among the complications of lung following transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma. We report a case of hepatopleural fistula complicated by TACE. A 50-year-old male was admitted to the hospital because of aggravation of cough and chest pain. Fifty five days before admission, a liver abscess had developed and treated by percutaneous drainage. A hepatocellular carcinoma had been diagnosed as a cause of liver abscess. Forty five days before admission, TACE had been performed for the hepatocellular carcinoma. Thirty days after TACE, dry cough and right pleuritic chest pain developed. After admission, serial CT scans of thorax and abdomen showed the pleural effusion containing the lipiodol from the liver through hepatopleural fistula. Chest tube insertion with a urokinase instillation was performed for the treatment of empyema caused by hepatopleural fistula.

Underlying Etiologic Factor of Recurrent Pneumothorax after Bullectomy / 대한흉부외과학회지

BACKGROUND: The cause of spontaneous pneumothorax is not yet but it is certain that intrathoracic air comes from ruptured bulla. Video-assisted thoracoscopic surgery(VATS) or open thoracotomy is recommended for thoracic incision in recurrent pneumothorax. However, recurrent rate after bullectomy with the VATS is very high compared to mini-thoracotomy, 3% to 20% and below 2%, respectively. MATERIAL AND METHOD: This retrospective analysis was performed on 16 re-operated cases among 446 surgically treated pneumothorax of the 737 cases of spontaneous pneumothorax diagnosed at Yongdong Severance Hospital from Nov. 1992 to June 1997. RESULT: Among the 446 surgically-treated patients in 737 case of spontaneous pneumothorax, 16 patients underwent re-operation, showing a 3.5% re-operation rate. Male-to-female ratio was 15 to 1 and mean age at initial attack was 20.2 years(ranging from 15 to 50). Mean hospital stay was 6.34 days(ranging from 2 to 20 days) and mean chest tube indwelling period was 4.2 days(ranging from 1-10 days). Median follow-up was 46 months(range 10-66 months). Three different surgical methods were applied : video-assisted thoracoscopic surgery(VAST) in 281 cases, of whom 2 underwent local anesthesia; subaxillary mini-thoracotomy in 159 cases and limited lateral thoracotomy in the remaining 6 cases. Three different re-operative surgical methods were applied ; video-assisted thoracoscopic surgery (VAST) in 6 cases, subaxillary mini-thoracotomy in 9 cases, and limited lateral thoracotomy in the remaining 1 case. The underlying etiological factors of the recurrent pneumothorax after bullectomy were o erlooking type(9) and new growing type(7). Mean recurrent period from previous operation was 1 month for overlooking type and 18 months for new growing type. CONCLUSION: The underlying etiological factors of recurrent pneumothorax lead to re-operation were new-growing and over-looking type. We need additional treatments besides resecting blebs of prevent the recurrence rate and more gentle handling with forceps due to less damage to the pleura.

Bleeding Tendency and Transfusion Feature after CABG / 대한흉부외과학회지

Postoperative autotransfusion is known as an effective method for blood conservation. We tried to examine whether the autotransfusion of shed mediastinal blood in patients with unstable angina would be valuable for reducing postoperative homologous transfusion by observing the hourly tendency of bleeding and transfusion. Between August and October, 1997, 26 patients with unstable angina underwent coronary arterial bypass surgery by a single surgeon at Asan Medical Center. In retrospective analysis, we found 90% of the patients received homologous transfusions and 85% of them were in the intensive care unit at the same day after operation. In many patients, the cause of transfusion was not anemia but volume replacement. Mean bleeding through the chest tubes was 340 cc for the first 5 hours and 69% (18 pts) showed more than 200 cc of bleeding, the amount generally considered as a initiating point for autotransfusion. Despite the adoption of multiple methods for blood conservation, 90% of the patients needed homologous transfusion. Moreover, many of them had received unnecessary transfusions. We conclude that some kind of blood for transfusion is needed during the immediate postoperative period, and the adoption of postoperative autotransfusion may help in reducing homologous transfusion.