Minimally Invasive Thoracic Surgery - Video Assisted Thoracic Surgery: Technique and Indications.

Video-Assisted Thoracic Surgery (VATS) is already practised worldwide, in almost every condition addressed by open thoracic surgery. As part of minimally invasive thoracic surgery (MITS), VATS offers to patients and to healthcare providers excellent results and great satisfactions. Learning and performing VATS use different pathways in trainees and in experienced surgeons. This article presents VATS in its essence: classification, indications, contraindications, instruments and tools, incisions and access, troubleshooting, learning curve and training. We wish that the information helps our colleagues, both trainees and experienced thoracic surgeons, to start and continue performing VATS as standard care in thoracic surgery.

Successful Implementation of HITOC and HIPEC in the Management of Advanced Ovarian Carcinoma with Pleural and Peritoneal Carcinomatosis.

This case report details the application and outcomes of a novel therapeutic approach involving hyperthermic intraperitoneal chemotherapy (HIPEC) and hyperthermic intrathoracic chemotherapy (HITOC) in a single patient diagnosed with advanced ovarian neoplasm. The treatment protocol included pleural cytoreductive surgery (CRS) and HITOC followed by a second surgical intervention consisting of peritoneal CRS and HIPEC. HIPEC targeted the intraperitoneal space with heated chemotherapy, while HITOC extended the thermal perfusion to the thoracic cavity. The patient has shown significant progression in disease-free survival over one year and eight months of observation, demonstrating lower recurrence rates and an overall survival outcome exceeding expectations based on conventional therapy outcomes. The combined modality demonstrated a manageable toxicity profile, with no significant increase in peri- or postoperative complications observed.

[The Montgomery tracheal prosthesis: actual solution for tracheal stenosis]. / Proteza traheala Montgomery: solutie de actualitate pentru stenozele traheale.

Tracheal stenosis is a disorder which is very difficult to diagnose in its early stages. Most cases are reffered to the hospital with an obstruction of at least 50% of the tracheal lumen, when dyspnea is already symptomatic. The cases with obstructive phenomena of over 70% represent immediately endoscopic emergencies, due to the risk of decompensation by adding the obstruction secondary to tracheo-bronchial secretions and bleeding. Initial management of a compromised central airway by endoscopic technique allows to obtain optimal conditions for the curative treatment. The main cause is malignancy and the for treatment are used endoscopic techniques with palliative visa. After restoring the permeability of the affected airways, stenting is mandatory to keep them open. Among the first stents invented, there was Montgomery type in 1965. Besides the silicon stent, there are the newest type, metallic or hybrid, which try to compensate disadvantages of silicone type, but with significant financial costs. Though Montgomery stent appeared more than 50 years ago, they are still used with good results, with clear advantages, especially in low incomes public health systems. The paper presents technical data, indications, advantages, disadvantages and techniques for effective placement. It also presents a well-documented clinical case of effective placement of a tracheal stent, with video-documentation of the whole procedure performed by a mix team: endoscopist and surgeon.

Giant left-sided pleuropericardial cyst, mimicking a heart disease.

Mediastinal cysts (MC) mainly have an embryonic origin, are benign and frequently discovered thanks to tomodensitometry, sometimes by magnetic resonance imaging. Rarely symptomatic, excepted in cases of very large cysts, they are mainly pleuropericardic cysts (PPC) that represent 30% of MC Surgery is commonly performed by videothoracoscopy or by video-assisted mini-thoracotomy, mainly for PPC We report the case of a 62-year-old woman, smoker (30 packs years), who is hospitalized in Constanta Pneumology Hospital in June 2011 for slight shortness of breath, sweating, pain in the left hemi thorax, minor hemoptysis, recurrent. In her medical history, there are to be noticed a blood transfusion after hysterectomy for uterine fibroma (1995), arterial hypertension (2006). After admission, X-ray exam of the chest shows cardiomegaly and a few lung nodular lesions in the right upper lobe. An initial differential diagnosis includes congestive heart failure, dilated cardiomyopathy, valvular heart disease, left pleurisy, pericarditis, paracardiac tumor mass, tuberculosis +/- HIV. Following laboratory tests imaging (chest CT and ultrasound performed in June 26th 2011 and 27h) a possible pleuropericardic cyst was suspected. Exploratory thoracentesis was not performed and, a month later, in the Institute of Pulmonology "Marius Nasta" Bucharest, a left open thoracotomy revealed a cystic formation about 10 cm in diameter. Histopathologic exam confirmed the diagnosis of cyst pleuropericardic. The prognosis after surgery was favorable. As a feature of the case are worth mentioning: the large size of pericardial cyst at the upper limit of the data reported in the literature, which mimics cardiomegaly, the hemoptoic onset in a hypertensive patient, heavy smoker; the late suspicion of pleuropericardic cyst through pleural echographic exam; the atypical localization; the facilitated certain diagnosis by surgery and hystological exam; the favorable postoperative prognosis; and all morbidities cofound (Pulmonary Tuberculosis, bronchiectasis, COPD).

A rare case of lung tumor -- pulmonary inflammatory pseudotumor.

Pulmonary inflammatory pseudotumor (PIP) is a rare condition of unknown etiology. It is still a matter of debate if it represents an inflammatory lesion characterized by uncontrolled cell growth or a true neoplasm. Although mostly benign, these tumors are diagnosis and therapeutic challenges. Preoperative diagnosis can rarely be established. The treatment of choice is surgical resection which has both diagnostic and therapeutic value. We report the case of a 63-year-old male presented with clinical and imagistic picture suggestive of malignancy in the thorax. Lobectomy was performed with histological diagnosis of PIP. No evidence of tumor recurrence.

[Iatrogenic tracheal stenosis in patients with COPD: a medico-surgical challenge]. / Stenoza traheala iatrogena la pacientul cu BPOC: o provocare medico-chirurgicala.

This study analyzes a series of iatrogenic tracheal stenosis occurring in patients with COPD exacerbation which required oro-tracheal intubation. The tracheal stenosis occurred on average after 24 days of intubation and were clinically severe. Treatment algorithm first included bronchoscopic interventional techniques with an immediate success rate of 37%, but the results were unstable in time, requiring tracheal stenting. The surgical approach, which generally is the first choice in the treatment of tracheal stenosis, had discouraging results in these patients, with a low rate of success (20%) and an increased incidence of restenosis. The only solution for those postoperative complications was, again, interventional bronchoscopy. In conclusion, while for various other etiologies of tracheal stenosis the surgical resection is the first choice of treatment, in COPD patients interventional bronchoscopy often remains the only way of solving.

[Tracheal stenosis--diagnostic and therapeutic principles, results]. / Stenozele traheale--principii de diagnostic si tratament, rezultate.

Between November 2001-April 2010, 107 tracheal resections were performed in our department for different types of tracheal stenosis: iatrogenic or tumoral, benign or malignant. We present the diagnosis and treatment principles that we used, along with our results. We operated on 74 (69.15%) iatrogenic postintubation tracheal stenosis, 6 (5.6%) of them complicated with tracheo-esophageal fistula, 6 (5.6%) benign tumors, 11 (10.28%) primary malignant and 16 (14.97%) secondary malignant ones, with a 3.8% total mortality. Tracheal resection and reconstruction is the only curative treatment for all types of tracheal stenosis. Interventional endoscopy is of a major importance in the assessment and treatment of tracheal stenosis. We believe that each patient diagnosed with a tracheal stenosis should be referred to a tertiary center with multidisciplinary experience in the treatment of tracheal stenosis.

[Preoperative evaluation for pulmonary resections in COPD patients]. / Evaluarea preoperatorie a pacientilor cu BPOC în vederea interventiilor chirurgicale toracice de rezectie pulmonara.

Chronic obstructive pulmonary disease - COPD, being one of the most frequent chronic pathologies in the world, an important number of such patients can necessitate, at a certain moment, a thoracic surgical intervention, especially pulmonary resections for pulmonary carcinoma. In these cases, the removing of a certain volume of pulmonary tissue from a patient who already has a respiratory malfunction necessitates a judicious preoperative evaluation to establish the correct indication, risk factors and postoperative prognosis (at least regarding the pulmonary function). Although the preoperative evaluation for pulmonary resections has been studied for many years, a parameter has not been found yet, simple or combined, to accurately predict the outcome. The majority of the candidates for pulmonary resections can be operated without previous complicated tests like CPET (cardio-pulmonary exercise testing) and regional pulmonary function, which are expensive and sometimes non accessible. In the past years, CPET gained more and more field in the appreciation of the surgical risk; combined with the split measurement of the function of the two lungs, it can even predict the postoperative effort capacity. In the complex preoperative evaluation of the chronic pulmonary patients we must not forget other, not so obvious aspects, so that the patient could benefit by the optimum moment and health status for his or her operation, for the purpose of a better prognosis.

[Multi-level digestive stenosis: of the lower esophagus and postbulbar duodenum--a surgical solution. Case report]. / Stenoze digestive etajate: esofagiana inferioara si postbulbara solutie chirurgicala.

Barrett esophagus is a rare medical entity. We present the case of a 56 years female patient admitted in our clinic for surgical treatment of a complication of a rigid stenosis of the lower esophagus. The situation is particular by the presence of two digestive strictures due to the same cause: gastric acid aggression. The steps of therapy of Barrett esophagus are reviewed, as well as the surgical options for choosing the best digestive segment able to replace the resected esophagus. The excellent immediate and long-term postoperative evolution allow us to believe that the surgical solution we used was the most appropriate and that the resected stomach can be successfully employed as a substitute for the esophagus after the resection of its lower half.