Pleurodesis.

Symptomatic pleural disease, specifically malignant pleural effusion, refractory benign pleural effusion, and pneumothoraces are common diseases that often require therapeutic interventions. The spectrum of management strategies often includes selection of a chemical pleurodesis agent administered in combination with an indwelling pleural catheter or chest tube.Additionally, there is a role for minimally invasive techniques which include medical thoracoscopy or more advanced video-assisted thoracoscopic approaches. Ongoing clinical trials continue to evolve best practices regarding the optimal sclerosant agents and procedural approaches in the management of these diseases.

[Pleural cavity concerns]. / Los quebraderos de cabeza del espacio pleural.

INTRODUCTION: Persistent air leak (PAL) is a common problem. We asses our experience in the management of these patients. MATERIAL AND METHODS: Retrospective review of patients with chest tubes after bronchopulmonary pneumothorax (due to lung resections, spontaneous pneumothorax, necrotizing pneumonia) from 2010 to 2015. We studied clinical data, PAL incidence, risk factors and treatment, considering PAL ≥ 5 days. RESULTS: Thirty-seven cases (28 patients) between 0-16years: 26 lung resections, 11 pneumothorax. We found no differences in the distribution of age, weight, indication or comorbidity, but we noticed a trend to shorter hospital stay in infants. Patients with staple-line reinforcement presented lower PAL incidence than patients with no mechanical suture (43% vs 37%), the difference is even apparent when applying tissue sealants (29% vs 50%) (p > 0.05). We encountered no relationship between the size of the tube (10-24 Fr) or the type of resection, with bigger air leaks the higher suction pressure. We performed 13 pleurodesis in 7 patients (2 lobectomies, 3 segmentectomies and 2 bronchopleural fistulas), with 70% effectiveness. We conducted 7 procedures with autologous blood (1.6 ml/kg), 2 with povidone-iodine (0.5 ml/kg), 2 mechanical thoracoscopic and 2 open ones. We repeated pleurodesis four times, 3 of them after autologous blood infusion: 2 infusions with the same dose (both effective) and the other 2 as thoracotomy in patients with bronchopleural fistulas. After instillation of blood 3 patients presented with fever. After povidone-iodine instillation, the patient suffered from fever and rash. CONCLUSIONS: Intraoperative technical aspects are essential to reduce the risk of PAL. Autologous blood pleurodesis, single or repeated, is a minimal invasive option, very safe and effective to treat the parenchymatous PAL.

INTRODUCCION: La fuga aérea persistente (FAP) es un problema común. Evaluamos nuestra experiencia en el manejo de estos pacientes. MATERIAL Y METODOS: Revisión retrospectiva 2010-2015 de pacientes con drenaje endotorácico por neumotórax broncopulmonar (resecciones pulmonares, neumotórax, neumonía necrotizante). Revisamos datos clínicos, incidencia de FAP, factores determinantes y tratamiento, considerando FAP ≥ 5 días. RESULTADOS: Treinta y siete casos (28 pacientes) con edades entre 0-16 años: 26 resecciones pulmonares, 11 neumotórax. No encontramos diferencias en distribución de edad, peso, indicación quirúrgica ni comorbilidad, aunque sí tendencia a menor estancia hospitalaria en lactantes. Los pacientes con sutura no mecánica presentaron más fugas que los pacientes con sutura mecánica (43 vs 37%), así como los pacientes a los que no se aplicaron sellantes tisulares (29 vs 50%) (ambos p > 0,05). No encontramos relación con el tamaño del tubo (10-24 Fr) ni con el tipo de resección, manteniendo más fuga aérea los de mayor presión de aspiración. Realizamos 13 pleurodesis en 7 pacientes (2 lobectomías, 3 segmentectomías y 2 fístulas broncopleurales), con efectividad del 70%. Realizamos 7 con sangre autóloga (1,6 ml/kg), 2 con povidona iodada (0,5 ml/kg), 2 mecánicas toracoscópicas y 2 abiertas. Se repitió la pleurodesis en 4 ocasiones, 3 de ellas tras sangre autóloga: dos con repetición de la misma dosis (ambas efectivas) y otras dos por toracotomía en los pacientes con fístula broncopleural. Tras la instilación de sangre 3 casos presentaron fiebre. Tras la de povidona iodada, fiebre y exantema. CONCLUSIONES: Los aspectos técnicos intraoperatorios son esenciales para disminuir el riesgo de FAP. La pleurodesis con sangre autóloga, única o repetida, es una opción poco invasiva, muy segura y efectiva para las FAP parenquimatosas en nuestra muestra.

Empyema caused by Actinomyces odontolyticus: A case report.

RATIONALE: Actinomyces odontolyticus causes a rare, chronic granulomatous infection that is frequently associated with immunocompromised states. A odontolyticus can cause infection in multiple organs, but empyema is rare. PATIENT CONCERNS: We report a case of empyema caused by A odontolyticus. The patient was a 64-year-old man. He was admitted to the hospital with a 5-day history of fever and dyspnea. He had caries and sequelae of cerebral apoplexy. DIAGNOSES: Metagenome next generation sequencing of pleural effusion was positive for A odontolyticus. Pathogen was identified by biphasic culture of pleural effusion fluid. INTERVENTIONS: According to the drug sensitivity test, linezolid 0.6 g twice daily and clindamycin 0.6 g 3 times a day were administered intravenously. Thoracic drainage was initially performed, but the drainage was not sufficient. Medical thoracoscopy was performed to fully drain the pleural effusion. OUTCOMES: After anti-infection and medical thoracoscopic therapy, the symptoms of this patient improved. LESSONS: Microbial metagenome sequencing can find pathogens that are difficult to culture by traditional methods. Adequate drainage was the key to the treatment of empyema. Medical thoracoscopy was recommended to remove the pleural effusion and spoilage when thoracic drainage is difficult. The common clinical features of A odontolyticus include a mass or swelling, abdominal disease, dental disease, and subcutaneous abscesses. Microbial metagenome sequencing can find pathogens that are difficult to culture by traditional methods. Adequate drainage was the key to the treatment of empyema. Medical thoracoscopy was recommended to remove the pleural effusion and spoilage when thoracic drainage is difficult.

Cyanoacrylate Tissue Adhesive After Chest Tube Removal in Children.

Background: After open or thoracoscopic lung biopsy, it is common to leave a chest tube as a postoperative drain that is typically removed on the first or second postoperative day. Standard technique is to apply an occlusive dressing at the site of chest tube removal using gauze and some form of tape. Methods: We reviewed the charts of children who underwent thoracoscopic lung biopsy at our institution for the past 9 years, many of whom left the operating room with a chest tube. When the tube was removed, the site was dressed, based on attending surgeon preference, with either cyanoacrylate tissue adhesive (Dermabond®; Ethicon, Cincinnati, OH) or a standard dressing with gauze and transparent occlusive adhesive dressing. Endpoints included wound complications and need for a secondary dressing. Results: Of 134 children who underwent thoracoscopic biopsy, 71 (53%) were given a chest tube. Chest tubes were removed at bedside in standard manner after a mean of 2.5 days. In 36 (50.7%) cyanoacrylate was used and in 35 (49.3%) a standard occlusive gauze dressing was used. No patient in either group suffered a wound dehiscence or needed a rescue dressing. There were no wound-related complications or surgical site infections in either group. Conclusion: Cyanoacrylate dressings are effective for closure of chest tube drain sites and appear to be safe. They might also save patients from having to deal with a bulky bandage and the discomfort of having a strong adhesive removed from their surgical site.

Secure closure of the tracheal incision after natural orifice transluminal endoscopic surgery with a surgical sealant (CoSeal).

BACKGROUND: To evaluate the effectiveness of surgical sealant (CoSeal) in sealing the tracheal assess sites after transtracheal thoracoscopy. METHODS: Two dogs underwent transtracheal thoracic exploration and pericardial window creation. The thoracic cavity was approached with flexible bronchoscope through a 9-mm tracheal incision. The pericardial window was performed with a needle knife via the working channel of the bronchoscope, and the tracheal assess site was closed with CoSeal using a rubber catheter. The integrity of tracheal healing was evaluated under positive pressure ventilation. RESULT: Transtracheal creation of pericardial window and closure of tracheal incision with CoSeal was successfully performed in both dogs. There was no evidence of air leaks from the chest tube during positive pressure ventilation. Autopsy revealed no injury to the mediastinum and intrathoracic structure. CONCLUSION: Endoscopic closure of tracheal access site of NOTES with CoSeal appears to be a feasible technique.

Multimedia article. Thoracoscopic patch repair of a right-sided congenital diaphragmatic hernia in a neonate.

PURPOSE: Minimally invasive techniques continue to expand in pediatric surgery; however, there has been some debate over the appropriate operative technique for the management of congenital diaphragmatic hernias in neonates. We present a video of a thoracoscopic patch repair of a right-sided Bochdalek congenital diaphragmatic hernia (CDH) in a 3-day-old male. METHODS: Our patient was noted to have a right-sided CDH on chest X-ray following respiratory distress at the time of birth. The patient's remaining neonatal workup also confirmed hypoplastic transverse aortic arch with coarctation, ventricular septal defect (VSD), and patent ductus arteriosus, which were initially diagnosed by prenatal ultrasound. After monitoring the patient for hemodynamic stability and discussion with the family and involved pediatric cardiothoracic surgeons, the decision was made to proceed with a thoracoscopic repair of the CDH. RESULTS: The large right-sided CDH was noted to involve herniated small bowel, colon, and liver. The diaphragmatic defect was successfully repaired thoracoscopically using a 5 x 5 cm polytetrafluoroethylene (PTFE) patch. The patient was extubated on the second postoperative day and ultimately underwent aortic arch augmentation, VSD closure, and patent ductus arteriosus ligation and division at 1 month of age. There has been no evidence of CDH recurrence in follow-up. CONCLUSIONS: As demonstrated by our video, large right-sided congenital diaphragmatic hernias requiring patch repair can be successfully repaired thoracoscopically with appropriate surgeon comfort and experience. This minimally invasive approach may also be used in neonates with associated cardiac defects with appropriate cardiothoracic surgical consultation and support. To our knowledge this is the first reported case of a thoracoscopic repair of a Bochdalek (posterolateral) hernia with a prosthetic patch in a neonate with significant congenital cardiac anomalies.

Liposomal Bupivacaine Enhances the Pain-Control Benefits of Uniportal Thoracoscopic Lobectomy.

BACKGROUND: Liposomal bupivacaine field block is gaining popularity as a critical element of enhanced recovery after surgery protocols in thoracic surgery. Uniportal thoracoscopic surgery has been reported to result in less narcotic consumption compared with traditional video-assisted thoracoscopic surgery. The objective of this study was to evaluate the postoperative narcotic consumption of patients undergoing uniportal thoracoscopic lobectomy with the use of 0.25% bupivacaine vs patients treated with liposomal bupivacaine. METHODS: All consecutive patients undergoing uniportal thoracoscopic lobectomy at an academic medical institution were recorded between October 2015 and February 2018. Narcotic consumption was converted to oral morphine equivalents by using standard formulas. Patients underwent posterior serratus and intercostal nerve blocks with 0.25% bupivacaine or liposomal bupivacaine, transitioning to liposomal bupivacaine in March 2017. Other adjuncts such as gabapentin or cyclooxygenase-2 inhibitors were not administered. RESULTS: Data were reviewed on 32 patients receiving field blocks with 0.25% bupivacaine and on 50 patients receiving liposomal bupivacaine. There was no difference between groups with regard to age, sex, chest tube duration, or length of stay. Patients undergoing field blocks with liposomal bupivacaine consumed less narcotic medication. CONCLUSIONS: The study investigators have previously demonstrated decreased narcotic consumption with the use of uniportal technique over traditional multi-incision thoracoscopic surgery. The use of liposomal bupivacaine for posterior serratus and intercostal field blocks enhanced pain control and decreased narcotic consumption.

Thoracoscopic retrieval of a "smiling" foreign body from the proximal esophagus: an impacted denture.

BACKGROUND: The esophagus is a common site for foreign bodies (FBs) because of areas of physiologic narrowing. Dentures pose special problems, especially if they are impacted. We present a case of a "smiling" foreign body in the proximal esophagus. CASE REPORT: The patient was an 80-year-old man with a history of dysphagia and swallowed dentures. Thoracoscopic removal was performed successfully as an endoscopic removal had failed and the patient had an uneventful postoperative recovery. He was discharged on the seventh postoperative day. DISCUSSION: Coins are the most commonly ingested FBs. Swallowing of dentures is found mostly in elderly patients. If endoscopic removal is not possible, then a minimally invasive surgery is an alternative. Swallowing of dentures is rare, and its thoracoscopic removal has not been reported so far. Using thoracoscopy, all the benefits of a minimally invasive surgery can be used. CONCLUSIONS: Minimally invasive techniques have been found to be very useful in the removal of intraluminal FBs, especially when conservative measures fail. Prevention of such incidents should be emphasized.

Covering the staple line with polyglycolic acid sheet versus oxidized regenerated cellulose mesh after thoracoscopic bullectomy for primary spontaneous pneumothorax.

OBJECTIVE: The aim of this study was to compare coverage with oxidized regenerated cellulose mesh and that with polyglycolic acid sheet to decrease the incidence of postoperative recurrent pneumothorax. METHODS: From August 2010 to August 2014, a total of 112 patients with primary spontaneous pneumothorax undergoing thoracoscopic bullectomy were enrolled. We compared the clinicopathological characteristics between recurrent and non-recurrent cases and examined their association with the material used for visceral pleural coverage: polyglycolic acid sheet versus oxidized regenerated cellulose mesh. RESULTS: 57 patients underwent thoracoscopic bullectomy plus coverage using oxidized regenerated cellulose mesh and 55 underwent thoracoscopic bullectomy plus coverage using polyglycolic acid sheet. The recurrence rate among all patients was 13.3%. No severe postoperative complications were observed in either group. There were no significant differences in the perioperative outcomes. However, the postoperative recurrence rate was significantly higher in the oxidized regenerated cellulose mesh group than in the polyglycolic acid sheet group (22.8 vs 3.6%). CONCLUSIONS: Our results suggest that coverage with oxidized regerated cellulose mesh was not superior to coverage with polyglycolic acid sheet for postoperative recurrent pneumothorax.

The use of biosynthetic mesh to separate the anastomoses during the thoracoscopic repair of esophageal atresia and tracheoesophageal fistula.

Recurrent tracheoesophageal fistula following the repair of esophageal atresia and tracheoesophageal fistula (EA/TEF) is a difficult complication to manage, which makes prevention the dominant concern of surgeons performing the primary repair. To this end, the surrounding pleural tissues are usually brought over the tracheal closure to prevent the development of a recurrence during the open repair. This maneuver is not usually feasible when using the thoracoscopic approach. Therefore, in this paper, we describe a case in which we interposed a biosynthetic mesh between the esophageal and tracheal suture lines during the thoracoscopic repair of EA/TEF on a 2.9-kg newborn girl.

Local and systemic effects of fibrin and cyanoacrylate adhesives on lung lesions in rabbits.

OBJECTIVES: Tissue adhesives can be used to prevent pulmonary air leaks, which frequently occur after lung interventions. The objective of this study is to evaluate local and systemic effects of fibrin and cyanoacrylate tissue adhesives on lung lesions in rabbits. METHODS: Eighteen rabbits were submitted to videothoracoscopy + lung incision alone (control) or videothoracoscopy + lung incision + local application of fibrin or cyanoacrylate adhesive. Blood samples were collected and assessed for leukocyte, neutrophil and lymphocyte counts and interleukin-8 levels preoperatively and at 48 hours and 28 days post-operatively. After 28 days, the animals were euthanized for gross examination of the lung surface, and lung fragments were excised for histopathological analysis. RESULTS: Fibrin and cyanoacrylate produced similar adhesion scores of the lung to the parietal pleura. Microscopic analysis revealed uniform low-cellular tissue infiltration in the fibrin group and an intense tissue reaction characterized by dense inflammatory infiltration of granulocytes, giant cells and necrosis in the cyanoacrylate group. No changes were detected in the leukocyte, neutrophil or lymphocyte count at any time-point, while the interleukin-8 levels were increased in the fibrin and cyanoacrylate groups after 48 hours compared with the pre-operative control levels (p<0.01). CONCLUSION: Both adhesive agents promoted normal tissue healing, with a more pronounced local inflammatory reaction observed for cyanoacrylate. Among the serum markers of inflammation, only the interleukin-8 levels changed post-operatively, increasing after 48 hours and decreasing after 28 days to levels similar to those of the control group in both the fibrin and cyanoacrylate groups.

Clinical experience of sleeve lobectomy with bronchoplasty using a continuous absorbable barbed suture.

Anastomosis in bronchoplasty is usually performed using interrupted sutures, which are considered safe, reliable, and secure. However, placing interrupted sutures can be complex and time-consuming. There have been recent reports of continuous suturing using standard suture materials in bronchoplasty. We have experienced four cases of sleeve lobectomy with bronchial anastomosis in continuous fashion using a novel absorbable barbed suture device, the V-Loc™ wound closure device (Covidien, USA), which facilitates secure wound closure without knot-tying. Two patients underwent sleeve upper lobectomy and two underwent sleeve upper-middle lobectomy. Surgical approach was completely thoracoscopic in one patient and open in three. There were no intraoperative difficulties such as cutting or loosening, and a leak test was negative in all cases. One patient had pneumonia postoperatively and developed anastomotic stenosis 4 months after surgery, which did not require treatment. All patients were alive, without local recurrence, at a mean follow-up of 11.5 months postoperatively.

A novel modified Nuss procedure for pectus excavatum: a new steel bar.

PURPOSE: The purpose of this article is to introduce a new modified Nuss procedure for pectus excavatum and to describe the configuration of the new steel bar. DESCRIPTION: We applied a novel method with a new steel bar for minimally invasive surgical correction of pectus excavatum. The procedure was performed with a new steel bar through bilateral thoracic minimally invasive incisions using a thoracoscope for guidance. The bar was installed or removed by pushing and pulling without turning it over. EVALUATION: One hundred forty-seven patients with pectus excavatum underwent this novel modified Nuss procedure. All patients had a satisfactory orthopedic result at discharge. There was no perioperative death or cardiac perforation. During the follow-up period, 134 patients underwent bar removal. Of the 134 cases, the initial orthopedic and functional results were excellent in 121 patients (90.3%) and good in 13 patients (9.7%). No patient had recurrence. CONCLUSIONS: This novel modified Nuss procedure is a safe, effective, and convenient treatment for pectus excavatum.

Evaluation of Three Sources of Validity Evidence for a Synthetic Thoracoscopic Esophageal Atresia/Tracheoesophageal Fistula Repair Simulator.

PURPOSE: Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator. MATERIALS AND METHODS: Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha. RESULTS: A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert. CONCLUSIONS: We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.

Thoracoscopic Thoracic Duct Ligation for Congenital and Acquired Disease.

PURPOSE: Congenital and acquired chylothorax presents a unique management challenge in neonates and infants. A failure of conservative therapy requires surgical ligation to prevent continued fluid and protein losses. This article examines a 15-year experience with thoracoscopic ligation of the thoracic duct. PATIENTS AND METHODS: From June 1999 to December 2013, 21 patients presented with chylothorax refractory to conservative management. Sixteen patients presented following cardiac procedures, 1 after tracheoesophageal fistula repair, 1 after extracorporeal membrane oxygenation cannulation, and 1 after trauma, and 2 had congenital chylothorax. Ages ranged from 3 weeks to 5 years, and weights ranged from 2.6 to 12.7 kg. All procedures were performed in the right chest with three ports. All cases consisted of sealing of the duct at the level of the diaphragm, a mechanical pleurodesis, and fibrin glue. RESULTS: All cases were completed successfully thoracoscopically. Operative time ranged from 20 to 55 minutes. There were no intraoperative complications. One patient with congenital bilateral chylothorax required a left partial pleurectomy. The chest tube duration postoperatively ranged from 4 to 14 days. Ligation failed in 2 patients, requiring a subsequent thoracoscopic pleurectomy and chemical pleurodesis, respectively. CONCLUSIONS: Thoracoscopic thoracic duct ligation is a safe and effective procedure even in post-cardiac surgery patients. The site of the leak can be identified in the majority of cases, and tissue-sealing technology appears to be effective. The minimally invasive nature of the procedure has led to more expedient operative repair to avoid the morbidity associated with chyle leak.

A new technique of thoracoscopic pleurodesis for refractory hepatic hydrothorax.

BACKGROUND: Hepatic hydrothorax is defined as a pleural effusion that arises in patients with cirrhosis of the liver and no cardiopulmonary disease; it is believed to result from peritoneopleural communication through a defect in the diaphragm. METHODS: Nine patients underwent thoracoscopic pleurodesis. The diaphragmatic defect was detected and corrected in two cases. In all patients, an argon beam coagulator was applied to the diaphragm surface, which was then completely covered with bioabsorbable prostheses. We then spread 3 ml of fibrin glue on the covered diaphragm and sprinkled 5 KE of OK-432 and 100 mg of minocycline hydrochloride in the thoracic cavity. RESULTS: All patients showed clinical improvement. The pleural effusion and breathlessness resolved immediately after pleurodesis. There were two recurrences after 1 and 4 months, respectively. One of these patients improved after repeat pleurodesis; the other was treated conservatively. CONCLUSION: Our new technique of thoracoscopic pleurodesis is an effective and minimally invasive treatment for patients with refractory hepatic hydrothorax.

Effectiveness of the fold plication method in lung volume reduction surgery.

OBJECT: The fold plication method is a new operative procedure for lung volume reduction surgery whereby the target area is obliterated by plicating the folded tissue using a knifeless stapler, without the use of bovine pericardium. The effectiveness of this new method was evaluated in patients with advanced pulmonary emphysema. PATIENTS AND METHODS: Two weeks before and 6 months after surgery, pulmonary function, static lung compliance, maximal esophageal pressure, maximal inspiratory and expiratory mouth pressures, 6-min walking distance and the Borg scale were determined in twenty consecutive patients who underwent video-assisted thoracoscopic unilateral surgery. RESULTS: There was an increase in forced expiratory volume in one second (31%), forced vital capacity, peak expiratory flow rate and maximal voluntary ventilation, and a decrease in functional residual capacity (-16%) measured by plethysmograph. Static lung compliance decreased, and maximal esophageal pressure, and maximal inspiratory and expiratory mouth pressures increased. The 6-min walking distance increased (20%) and the Borg scale decreased (5.9 to 3.5). CONCLUSION: The results compare favorably with those obtained with other methods. Thus, the fold plication method could be considered an alternative procedure for lung volume reduction surgery.

Staple-line reinforcement with a new type of polyglycolic acid felt.

Although various materials have been used for reinforcement in lung-volume-reduction surgery to buttress pulmonary staple-line, absorbable materials are not available for use in thoracoscopic surgery. Moreover, even nonabsorbable types of reinforcements have been used only for lung volume reduction surgery. However, elderly patients with spontaneous pneumothorax secondary to emphysematous lung are well treated with staple-line reinforcement. The authors developed a new type of polyglycolic acid felt to buttress staple-line. This felt is absorbable, easier to cut with a stapler knife than is the conventional polyglycolic acid felt, and inexpensive enough to use for various types of thoracic surgeries for emphysematous lungs in Japan, and it can be attached to staplers with a small amount of fibrin glue. These strips were used to reinforce pulmonary staple lines for resection of emphysematous lungs in 14 patients: pulmonary emphysema (n = 1), bilateral giant bullae (n = 1), ipsilateral giant bullae (n = 6), spontaneous pneumothorax with multiple bullae in an emphysematous lung (n = 5), and lung cancer in a patient with pulmonary emphysema (n = 1). There were no air leaks during surgery. Air leaks were noted in three patients after surgery. In two patients, the air leaks stopped within 2 weeks. In one patient, the air leak was found to originate from an untouched lobe during reoperation. No infection or allergic reaction developed in a patient during a mean follow-up of 12 months (range, 1 to 24 months).

Hand-assisted laparoscopic surgery for the abdominal phase in endoscopic esophagectomy for esophageal cancer: an alteration on the site of minilaparotomy.

The authors present an alteration at the site of a minilaparotomy in the abdominal phase of endoscopic esophagectomy and reconstruction by means of hand-assisted laparoscopic surgery. In the first case, a minilaparotomy was performed in the lower right side of the abdomen during laparoscopic construction of a gastric tube using hand-assisted laparoscopic surgery. However, this technique was not always feasible because an elaborate technique was necessary, even with the use of the surgeon's hand, which was inserted in the abdomen through the mini-incision. After the second case, the authors performed a minilaparotomy slightly above the stomach. The upper abdominal incision allowed easier and safer management of the gastric tube. This technique was also helpful in the Kocher maneuver and in the construction of the retrosternal route. The site of the minilaparotomy in the upper abdomen reduced the stress of this procedure, and, therefore, became the standard procedure for select patients at the First Department of Surgery, Tokyo Medical and Dental University.

[Trans-sternal approach to the cervicothoracic junction]. / Dojscie przez mostek do pogranicza szyjno-piersiowego kregoslupa.

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved toward less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection and partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.