Video-assisted thoracic surgery (VATS) lobectomy: 13 years' experience.

BACKGROUND: Major lung resection by video-assisted thoracic surgery (VATS) has been proven to be both safe and technically feasible, but is not routinely performed in most hospitals. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained. METHODS: We have performed a retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit, Virgen Macarena University Hospital, Seville (Spain) since 1992. The clinical records of all patients were drawn from the hospital archive and data for the following variables were recorded for analysis: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications, postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. We also describe our surgical technique for each lobectomy. RESULTS: A total of 237 major pulmonary resections were performed, on 203 males and 34 males, with a mean age of 61.43 years (non-small-cell bronchogenic carcinoma: 204, benign processes: 24, carcinoid tumors: 4, and lobectomy due to metastases: 5). The overall conversion rate was 14.01%. Mean duration of lobectomy was 153 min, with a median of 98 min, and mean postoperative stay was 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications. Perioperative mortality was 3.7%. The actuarial 5-year survival rate was 77.7%. CONCLUSIONS: VATS lobectomy is a viable safe procedure that meets oncological criteria for lung cancer surgery. In our experience, VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas.

Peripheral arterial embolism arising from pulmonary adenocarcinoma.

Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation.

Usefulness of videothoracoscopic intrapericardial examination of pulmonary vessels to identify resectable clinical T4 lung cancer.

BACKGROUND: Discrepancies in predicting resectability by imaging techniques (computed tomography and magnetic resonance imaging) compared with actual intraoperative findings have persuaded us to perform systematic exploratory videothoracoscopy (EVT) as the first step in the surgical evaluation of patients with lung cancer. Resectability of centrally located primary tumors with intrapericardial extension (clinical T4), however, can be established only by direct examination of the pericardial sac contents. Therefore, in these instances, videopericardioscopy (VPC) has been added to our protocol. METHODS: From April 1993 to December 2000, members of our department used EVT to assess 620 patients with lung cancer. Of them, 27 patients, 25 men and 2 women, were seen with pericardial tumor extension. The mean age of the group was 62 years (range, 41 to 77 years). To be properly evaluated, these patients underwent VPC. We used three and, occasionally, four incisions to perform EVT. The same incisions were used to enter the pericardial cavity during VPC. RESULTS: In 15 of the 27 patients, hilar and vascular invasion was correctly predicted by imaging techniques. The other 12, however, were correctly staged only during EVT. The tumor was deemed unresectable by VPC in 6 patients (5 with invasion at the origin of the pulmonary artery and 1 with involvement of the left inferior pulmonary vein and left atrium), and exploratory thoracotomy was obviated. There was no morbidity or mortality in these 6 patients, and their mean length of hospital stay was 48 hours. The remaining 21 patients underwent thoracotomy and intrapericardial lung resection. Six of them had been considered to have unresectable disease on the basis of computed tomographic findings or magnetic resonance imaging studies. An average of 22 minutes (range, 16 to 33 minutes) was added to the operation when VPC was used. CONCLUSIONS: This study suggests that EVT is superior to imaging techniques (computed tomography or magnetic resonance imaging) in detecting tumor extension into the pericardium. In addition, short of an exploratory thoracotomy, VPC seems to be the most definitive study to establish resectability of centrally located tumors with pericardial invasion. Unnecessary exploratory thoracotomies can thus be avoided.