Needlescopic video-assisted thoracic surgery for primary spontaneous pneumothorax.

Minimally invasive surgery is the current trend of approach in various fields. Since May 2006, our team has started implementing needlescopic video-assisted thoracic surgery as the standard surgical treatment for primary spontaneous pneumothorax. During a seventeen-month period, 62 consecutive patients with primary spontaneous pneumothorax were operated on. The ages, sex ratio, operative times, blood loss, postoperative pain in visual analog scale (VAS), length of stay and hospital costs were recorded and compared with that of another 62 consecutive patients who received conventional video-assisted thoracic surgery between July 2004 and April 2006. Only the postoperative pain in VAS was significantly lower in the needlescopic video-assisted thoracic surgery group; the rest remained the same. Also the wounds were almost undetectable in the needlescopic video-assisted thoracic surgery patients. There were no major complications, mortality or recurrence in either group. Needlescopic video-assisted thoracic surgery is a high-tech technique which provides safety, effectiveness, economy and outcome comparable to that of conventional techniques. It is also associated with less pain and better cosmetics.

Revisit of 1997 TNM staging system--survival analysis of 1112 lung cancer patients in Taiwan.

BACKGROUND: There is neither a nation-wide nor a large-scale, multi-institutional lung cancer database available for stage-by-stage survival analysis in Taiwan at present. METHODS: Using the data element provided by the International Association for the Study of Lung Cancer, the Taiwan Lung Cancer Society initiated a project to include native lung cancer patients into a global database. A total of 1112 Taiwan lung cancer patients treated in 7 medical centers were enrolled. RESULTS: In small cell lung cancer, patients with ipsilateral pleural effusion had a survival between those with locoregional disease alone and those with distant metastasis; however, the difference was not statistically significant (P = 0.204). In non-small cell lung cancer, tumor size had significant survival influence for patients as a whole (P < 0.001) but it did not support the further division of stage IA according to tumor size (P = 0.122). The survival was compatible in stage IIIB and IV patients and therefore, the survival impact of pleural effusion cannot be determined. In patients with pIIIA-N2 disease, those who had station 8 nodal metastasis had inferior survival (P = 0.020) and station 5 superior survival (P = 0.010). In patients with distant metastasis, bone, liver, or distant lymph node metastasis predicted an inferior survival (all P values < 0.05). CONCLUSIONS: The present study provides for comparison in this area a stage-by-stage reference for the survival of lung cancer patients. Some factors other than current TNM descriptors need to be further investigated in constructing the next version of the staging system.

Retrospective comparison of needle thoracoscopy and conventional thoracoscopic surgery to treat primary spontaneous pneumothorax.

OBJECTIVE: To retrospectively compare needle video-thoracoscopic surgery (NVTS) with conventional video-thoracoscopic surgery (CVTS) for the treatment of primary spontaneous pneumothorax. METHODS: The charts of 9 female and 66 male patients with onset of primary spontaneous pneumothorax between July 1999 and December 2005 were reviewed. Twenty-two patients in the NVTS group were treated with NVTS, using a needle-shaped thoracoscope and instruments (3-mm in diameter), and assisted by one 10-mm standard port, whereas 53 patients in the CVTS group were treated using conventional endoscopic devices with a 10-mm thoracoscope. All patients underwent endoscopic stapling to excise blebs if identified. Postoperative wound pain was scored using a numerical pain scale. RESULTS: Neither group experienced mortality or any major morbidity during mean follow-up of 80.5 months. In the NVTS and CVTS groups, intraoperative blood loss (11.4+/-14.8 and 17.4+/-18.1 mL respectively, P=0.174), and mean operative times (75.5+/-38.5 and 92.2+/-33.1 min, respectively, P=0.062) did not differ significantly. Mean durations of pleural drainage (0.6+/-1.0 and 2.6+/-2.3 d, respectively, P<0.01), and postoperative hospital stay (2.3+/-1.4 and 4.4+/-2.5 d, respectively, P<0.01) were less in the needle video-thorascopic surgery group. The degree of postoperative wound pain did not differ significantly between the 2 groups. There were 3 cases of persistent postoperative air leakage in both groups, which required further approaches to check for unrecognized blebs. There was no recurrence of pneumothorax in the NVTS group, and 3.6% recurrence rate in the CVTS group. CONCLUSIONS: Needle thoracoscopy seems to be a safe alternative to treat primary spontaneous pneumothorax.

Different outcomes between two sides after bilateral sympathetic ganglion interruption for hyperhidrosis.

BACKGROUND: Although the determination of the correct ganglion under direct vision through thoracoscopy by an experienced surgeon is almost unerring, there is still a 4.3% rate of clipping at the unintended level. METHODS: Through the review of the most recent patients (N = 117) with various sympathetic disorders undergoing thoracoscopic sympathetic interruption over different ganglions by clipping, we found that 5 cases were clipped at the unplanned level. The immediate manifestations were the different outcomes between both sides of the face, trunk, and extremities. The postoperative chest radiographs demonstrated the error. RESULTS: All patients received a second operation in which the unintended clip was removed, and a new one was applied to the appropriate ganglion. The results were satisfactory. CONCLUSIONS: Although the authors in this study have the experience of more than 1000 cases of hyperhidrosis, such an error is still inevitable. Luckily, by using the clipping method, the error is detectable and amendable.

Videothoracoscopic resection of stage II thymoma: prospective comparison of the results between thoracoscopy and open methods.

STUDY OBJECTIVES: Although videothoracoscopic (VTS) resection of Masaoka stage I thymoma has been reported to be a less invasive method than open thoracotomy and to achieve a comparable surgical outcome, the usefulness of this method in the treatment of stage II thymoma has not yet been prospectively evaluated. We therefore compared the VTS and open (median sternotomy) methods to see whether VTS resection could be used as successfully to treat stage II thymoma disease. DESIGN, SETTING, AND PATIENTS: Patients (11 women and 11 men) with stage II thymoma were prospectively enrolled between November 1999 and September 2004. Of these, 12 patients (the VTS group) underwent tumor resection using a three-port endoscopic technique, and 10 patients (the open group) underwent tumor excision using a standard sternotomy approach. The diagnosis of all resected thymoma lesions and their stage were confirmed by histopathogic examination. MEASUREMENTS AND RESULTS: Neither group experienced mortality or any major morbidity. The difference in mean age (+/- SD) between the VTS and open groups (40.2 +/- 16.3 years and 47.7 +/- 8.5 years, p = 0.202); mean operation time (193.3 +/- 79.6 min and 207.5 +/- 85.8 min, p = 0.692); mean duration of pleural drainage (4.2 +/- 2.1 days and 4.6 +/- 2.1 days, p = 0.702); and mean duration of postoperative hospital stay (6.8 +/- 2.3 days and 8.9 +/- 4.4 days, respectively; p = 0.157) were not statistically significant. However, mean intraoperative blood loss amounts were statistically different (119.2 +/- 70.6 mL and 238.5 +/- 110.2 mL, respectively; p = 0.006). During the mean follow-up period of 33.9 +/- 19.7 months, all patients survived without sign of recurrence, and the mean survival time was not statistically significant (32.3 +/- 22.0 months and 35.8 +/- 17.5 months, respectively; p = 0.686). CONCLUSION: Using careful and skillful technique, the VTS method is an effective treatment of stage II thymoma.

Overexpression of circulating c-met messenger RNA is significantly correlated with nodal stage and early recurrence in non-small cell lung cancer.

BACKGROUND: The c-met receptor and its ligand hepatocyte growth factor have been shown to be involved in tumor invasiveness and metastasis. Overexpression of c-met has been demonstrated in lung cancer tissues and cell lines, but the expression of c-met in peripheral blood (circulating c-met) has not been addressed. The molecular monitoring of circulating c-met could be helpful for selecting patients for adjuvant therapy. OBJECTIVES: To investigate the expression of circulating c-met in non-small cell lung cancer (NSCLC) patients and to assess its prognostic implications. METHODS: We quantified the levels of c-met messenger RNA (mRNA) in paired tumor and normal lung tissues and their peripheral bloods in 45 patients with NSCLC by real-time polymerase chain reaction (PCR). The expression status of c-met protein in tumor tissues was further evaluated by immunohistochemistry. RESULTS: c-Met mRNA was significantly higher by 1.5 to 11 times in 34 of 45 tumor tissues (75.5%) than it was in their normal counterparts by real-time PCR. A comparison of this assay to immunohistochemistry suggested that real-time PCR was more sensitive than immunohistochemistry (27 of 45 tumor tissues, 60.0%) for the detection of c-met (p = 0.016). Of these patients with overexpression of c-met in tumors, 67.6% (23 of 34 patients) expressed higher amounts of circulating c-met by 1.4 to 8 times that of the normal control subjects. In addition, overexpression of circulating c-met was significantly correlated with nodal (N) stage (p = 0.011), but weakly correlated with tumor (T) stage (p = 0.056) and overall stages (p = 0.054) in patients with NSCLC. However, no correlations were found among circulating c-met and other factors such as age, gender, and pathologic types. Moreover, by univariate analysis, circulating c-met overexpression and pathologic stages (including T and N stages) were the most important factors correlated with early recurrence (p < 0.05). Only the circulating c-met remained as an independent predictor of early recurrence (hazard ratio, 3.94; 95% confidence interval, 1.17 to 13.33; p = 0.027) after Cox regression multivariate analysis. CONCLUSIONS: Overexpression of circulating c-met is significantly correlated with the N stage and early recurrence. Moreover, early recurrence is frequently noted in patients with overexpression of circulating c-met, indicating that circulating c-met is an independent negative prognostic indicator in NSCLC.

Sympathetic hypertensive syndrome: a possible surgically curable type of hypertension.

Poorly controlled hypertension was incidentally cured after performing an endoscopic sympathetic block (ESB) in a patient with hyperhidrosis craniofacialis (HHC). A survey of the literature indicated that 30% to 40% of essential hypertension is of sympathetic origin. Patients with facial sweating associated with hypertension were then studied to determine whether blood pressure is lowered after performing ESB. Between November 2002 and July 2003, 17 hypertensive patients (13 males and 4 females) ranging in age from 22 to 62 years underwent ESB solely for HHC at the Department of Surgery of Kaohsiung Medical University, Taiwan. Their preoperative systolic blood pressure (SBP) values ranged from 170 +/- 6 to 200.7 +/- 7.6 mmHg, and their diastolic blood pressure (DBP) values ranged from 94.7 +/- 6.1 to 120.3 +/- 5.7 mmHg. Their heart rates were between 92.67 +/- 2.28 and 119.67 +/- 5.13 beats per minute (bpm). They were refractory to aggressive medical treatment, including lifestyle modifications and antihypertensive medications. Their postoperative blood pressure, heart rate and surgical outcomes were recorded. After performing ESB, HHC was cured in all 17 patients. Based on the reductions in blood pressure and heart rate, the patients could be divided into two groups, one showing high-level reductions (Group T) and one showing low-level reductions (Group S). The blood pressure of Group T (ten patients) was reduced to the range of 120.2 +/- 6.9 to 131.6 +/- 3.5 mmHg SBP and 74.8 +/- 3.1 to 85.4 +/- 4.5 DBP, and the heart rate of this group was reduced to the range of 65.36 +/- 4.63 to 85 +/- 3.60 bpm, while the blood pressure and heart rate of Group S (seven other patients) were reduced to the ranges of 145.9 +/- 5.7 to 160.5 +/- 5.5 mmHg SBP, 90 +/- 4 to 100.7 +/- 3.2 mmHg DBP, and 80 +/- 4 to 90.83 +/- 3.53 bpm, respectively. The patients in Group S were well controlled at 119.8 +/- 5.5 to 130.6 +/- 8.0 mmHg SBP and 70.1 +/- 3.8 to 84.5 +/- 5.7 mmHg DBP with a daily low-dose of calcium channel blocker. The average follow-up periods of the two groups were 17.00 +/- 2.906 and 17.43 +/- 2.37 months, respectively. We named this surgically curable form of hypertension "Sympathetic Hypertensive Syndrome" (SHS), which we define by the presence of all three of the following: 1) stage II hypertension; 2) HHC or other sympathetic disorders; and 3) heart rate > or = 100 bpm. If the patient is male the reductions of blood pressure after the surgery will be better, which might be due to the link with Y chromosome. Finally, we recommend that ESB should be performed in patients with SHS, although the female would respond less satisfactorily in terms of the blood pressure.

T4 sympathectomy for palmar hyperhidrosis: an effective approach that simultaneously minimzes compensatory hyperhidrosis.

Compensatory hyperhidrosis (CH) is the most troublesome side effect after T2 sympathectomy for palmar hyperhidrosis (PH). The aim of this study was to evaluate whether T4 ganglion interruption for PH is an effective approach that can simultaneously minimize the rate of CH. Between July 2001 and July 2003, 84 PH patients undergoing bilateral thoracoscopic T4 sympathectomy were followed up in the outpatient clinic and by telephone questionnaire. Rates of success, regret, CH, recurrence, and complications were recorded. The follow-up period ranged from 18 to 42 months. All excessive hand sweating was stopped. Only two patients had mild CH that did not affect their daily activities. No patients had recurrence or regret. The only other complication was that four patients had postoperative minimal residual pneumothorax, which needed no treatment. All patients were satisfied with the outcome. T4 sympathectomy was an effective method to cure PH. The success rate was 100%. The rate of CH was remarkably low compared with T2 sympathetic ganglionic interruption.

Transthoracic or transhiatal resection for middle- and lower-third esophageal carcinoma?

Transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE) are two common methods of resection for esophageal cancer. Although many studies have been performed in Western countries, there are still controversies over which method is the better procedure. In this study, postoperative improvement in dysphagia and the degree of postoperative pain were compared. The cases of 50 patients undergoing TTE and 23 undergoing THE for esophageal cancer between March 1997 and October 2002 were retrospectively reviewed. The location of the lesion, clinical stage (TNM), operative time, operative blood loss, hospital stay, complications, number of lymph nodes dissected, and survival duration were recorded. Pre- and postoperative dysphagia scores and postoperative pain perception (using a visual analog scale) were analyzed. Preoperative clinical stage and lesion site were not significantly different in the TTE and THE groups. The operative time was longer and the number of lymph nodes removed was larger in the TTE group. However, there were no differences in operative blood loss, hospital stay, complications, survival duration, and improvement in dysphagia. Pain perception in the THE group was significantly better than that in the TTE group. THE is a safe and rapid procedure, with recovery and survival periods similar to those for TTE. Both patient groups enjoyed the same ability to eat. Therefore, THE is an acceptable alternative to TTE for patients with middle- and lower-third esophageal cancer. Moreover, THE caused much less postoperative pain than TTE, which made patients more comfortable.

Prospective comparison between endosuturing and endostapling in treating primary spontaneous pneumothorax.

OBJECTIVE: Direct management of ruptured pulmonary blebs remains the definitive treatment for spontaneous pneumothorax. We compared endosuturing and endostapling performed via thoracoscopy to determine if suture closure of the blebs without resection was sufficient to treat primary spontaneous pneumothorax. METHODS: Nine female and forty-nine male prospective patients were prospectively enrolled into two groups between July 1999 and May 2003. The patients in the suturing group were treated with an endoscopic suturing technique to close existing blebs. Patients in the stapling group underwent endoscopic stapling to excise the blebs. Only three ports were needed for each procedure. RESULTS: Neither group experienced mortality or any major morbidity. There were no significant clinical differences between the suturing and stapling groups. The intra-operative blood loss was not significantly different (32.9+/-53.9 and 13.6+/-21.8 mL, respectively, P = 0.079). The duration of pleural drainage was not statistically significant (2.7+/-1.2 and 2.3+/-2.0 days, respectively, P = 0.369). The length of postoperative hospital stay was also not statistically significant (4.2+/-1.5 and 3.8+/-2.4 days, respectively, P = 0.386). However, the operative time was significantly longer in the suturing group (135.0+/-53.8 and 89.0+/-35.6 minutes, respectively, P < 0.05). In each group, there were two cases of recurrence during the 21.5+/-12.1 month followup period, all of which recovered well after retreatment. CONCLUSIONS: We believe that this is the first prospective study on thoracoscopic suture closure of blebs. By imbricating and buttressing the blebs without resection, the endosuturing method represents an effective way to treat primary spontaneous pneumothorax.

Video-assisted thoracoscopic suture closure of blebs to treat primary spontaneous pneumothorax.

BACKGROUND AND OBJECTIVES: If surgery is indicated for primary spontaneous pneumothorax (PSP), video-assisted thoracoscopic surgery (VATS) using an endoscopic linear cutter to resect the involved blebs is the most popular treatment. We tried to determine whether closure of the blebs with sutures without resection is also efficacious enough to treat PSP. METHODS: We prospectively analyzed 22 episodes of PSP in 21 patients from January 2001 to April 2002. We endosutured the blebs, without removing them, no matter what the size and the number of the blebs were. Coagulation pleurodesis was added in every case. Only 3 ports were needed during the procedure. RESULTS: Morbidity and cost efficiency were acceptable. Two recurrences were experienced. The reasons for the recurrences were poor performance of the endo-suture in 1 patient, and no obvious blebs found in the other. CONCLUSIONS: We believe that VATS wedge closure of blebs by imbricating and buttressing them, without resection, is a feasible and effective alternative treatment for primary spontaneous pneumothorax.

Exogenous lipoid pneumonia: serial chest plain roentgenography and high-resolution computerized tomography findings.

Between May 1988 and July 2002, six patients with pneumonia due to diesel, animal, or vegetable oil aspiration were admitted to Kaohsiung Medical University Hospital. The purpose of this study was to demonstrate distinctive radiographic findings of oil-induced lipoid pneumonitis on initial serial chest roentgenograms and high-resolution computerized tomography (CT) scans. Initial chest roentgenograms (n = 6), CT scans (n = 6), and roentgenography and CT follow-up studies were analyzed retrospectively by two chest radiologists and two surgeons, focusing on the pattern and distribution of parenchymal abnormalities. The most common location was the right middle lobe, followed by the right lower lobe, the left lower lobe, and the lingular lobe. Follow-up chest roentgenograms (n = 6) showed complete disappearance of the parenchymal lesions in only one patient and partial decrease in the extent of lesions in five patients. Lipoid pneumonia presents non-specific findings on chest roentgenography. It is commonly located in both lower and the right middle lobes. On high-resolution CT, the lesions appear most commonly as areas of consolidation, ground-glass attenuation mixed with paving pattern, and poorly defined nodules.

Do pulmonary hemodynamics change after effective lung volume reduction surgery for emphysema?

The improvement in lung function, exercise test, blood gas levels, and symptoms in emphysema patients after volume reduction surgery is a result of improvements in breathing mechanics. The question is, is the improvement in the condition related to pulmonary hemodynamics? Few studies have examined pre- and postoperative pulmonary pressure. This paper examines whether there is any significant change in systolic and diastolic pulmonary pressure after effective volume reduction surgery. From October 1999 to October 2002, 12 emphysema patients who underwent volume reduction surgery were studied. Systolic and diastolic pulmonary pressures were measured 2 days before surgery through cardiac catheterization and 2 days after removal of the chest tubes through Swan Ganz catheters placed in the operating room just before surgery. Patients were stable and breathed without assistance during the postoperative pressure measurement. Blood gas analysis, lung function tests, and a 6-minute walk test were performed preoperatively and 3 months postoperatively. The two sets of data were compared using the Wilcoxon signed rank test. There was no significant change in pulmonary hemodynamics, although pulmonary function improved. The improvement in pulmonary function after volume reduction surgery is not related to pulmonary hemodynamics.

Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated?

OBJECTIVES: More than 50% of patients with primary spontaneous pneumothorax have contralateral blebs/bullae, and about a quarter will develop a contralateral pneumothorax. The purpose of this prospective study was to determine the need for elective treatment of asymptomatic contralateral blebs/bullae in patients presenting with primary spontaneous pneumothorax. METHODS: From May 2006 through June 2008, results from 35 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs receiving unilateral video-assisted thoracic surgery, 35 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery, and 16 patients with ipsilateral primary spontaneous pneumothorax receiving bilateral video-assisted thoracic surgery for positive contralateral blebs were collected. Their demographic and operating data were also recorded. RESULTS: There was no significant difference in age, gender, smoking percentage, body mass index (kg/m(2)), blood loss, and postoperative pain among groups. There was longer operative time and length of stay in group receiving bilateral surgery. Within the follow-up period of 16.68 +/- 9.91 months (median, 17.50), no recurrence on either lung was found in the group operated on both sides, while contralateral occurrence was found in 17.14% of the group with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery within the period of 18.15 +/- 8.07 months (median, 21). CONCLUSION: The study showed that the preemptive video-assisted thoracic surgery for the contralateral blebs/bullae effectively prevented the contralateral occurrence.

Expandable metal stents as an alternative treatment of cuff-related tracheal stenosis in tracheostomy-dependent ventilated patients: a prospective study of nine cases and description of the complications.

BACKGROUND AND AIMS: In long-term intubated patients, cuff-related tracheal injury is occasionally complicated by tracheal stricture. To keep the airway patent, bougienage and deployment of stents are adopted in patients unfit for surgery. MATERIALS AND METHODS: Prospectively, nine episodes of cuff-related tracheal stricture in nine tracheostomy-dependent ventilated patients were treated with pre-stenting bougienage, followed by implantation of expandable metal stents (EMS). The primary endpoint of this study was the successful discharge of the patients back to the chronic care unit. The other endpoint was the re-treatment rate. RESULTS: The mean age of the nine patients was 61.7 years. The follow-up period was 18.6 months. The first two patients received a bare stent, and the other seven patients received membrane-coated stents. They all recovered well with successful discharge back to the chronic care unit. There were two episodes of granulation formation in one bare-stent patient and in one coated-stent patient, respectively. In another coated-stent patient, complications arose from a broken stent. CONCLUSION: EMS appears to have a role to play in tracheostomy-dependent ventilated patients with benign tracheal stenoses in whom there are no other reasonable options.

Characteristics of thymoma successfully resected by videothoracoscopic surgery.

PURPOSE: The inclusion criteria were established for a videothoracoscopic resection of early-stage thymoma. We retrospectively evaluated the validity of these criteria in the treatment of early-stage thymoma. METHODS: The computed tomography (CT) image characteristics and clinical information comprised these criteria. The image considerations included the location of the tumor in the anterior mediastinum, a distinct fat plane between the tumor and vital organs, unilateral tumor predominance, tumor encapsulation, the existence of residual normal-appearing thymic tissue, and no mass compression effect. All enrollees were expected to be free of pleural effusion, pericardial effusion, paralysis of the hemidiaphragm, and the encasement of great vessels. An elevation of either the serum alpha-fetoprotein or beta-human chorionic gonadotropin levels, severe chest pain, superior vena cava syndrome, hoarseness, and age less than 20 years excluded the patient from enrollment. The heterogeneous content of the tumor was not an exclusion criterion, and the tumor size was not considered important. According to the above criteria, 44 patients were enrolled between November 1999 and November 2005. RESULTS: Twenty-seven patients had stage I thymoma and 17 had stage II thymoma. All patients successfully underwent a complete tumor resection using a three-port endoscopic technique. There was no open conversion. CONCLUSIONS: Based on these criteria, we can select suitable patients to confidently perform a thoracoscopic resection of early-stage thymoma.

Video-assisted extrathoracic bleb excision: an ultra-minithoracotomy for primary spontaneous pneumothorax.

Video-assisted thoracic surgery (VATS) is the treatment of choice for uncomplicated primary spontaneous pneumothorax (PSP). In this study, we design a modified thoracoscopic procedure and compare it with the standard VATS. Between January 2001 and July 2003, fifty-two consecutive patients with PSP were managed with the modified procedure, called video-assisted extrathoracic bleb excision (VAEB). Simultaneously, we reviewed and recorded the same data of another consecutive 52 patients who underwent standard VATS between April 1997 and December 2000. The two groups were compared regarding operative time, intraoperative blood loss, postoperative pain by visual analog scale (VAS), amount of chest tube drainage, length of hospital stay (LOS), and hospital cost. The age, gender, amount of chest tube drainage, and LOS were not significantly different (P = 0.787, 0.727, 0.660, and 0.602, respectively). The operative time was shorter (VAEB 43+/-6 min; VATS 63+/-5 min), pain was less (VAS: VAEB 6+/-1; VATS 7+/-1) and hospital cost was lower (VAEB dollars 1429+/-37; VATS dollars 2035+/-93) in the VAEB group. VAEB is an effective alternative procedure to standard VATS for PSP. It has the same effectiveness as VATS and catches the advantages of transaxillary minithoracotomy. In addition, it is an easier, quicker, less traumatic and more economical approach.

Early video-assisted thoracic surgery for primary spontaneous hemopneumothorax.

INTRODUCTION: Primary spontaneous hemopneumothorax (PSHP) is a rare surgical emergency. The aim of this study was to compare the previous strategy of tube thoracostomy followed by thoracotomy when complications developed with early video-assisted thoracic surgery (VATS) for PSHP. METHODS: Between November 1989 and May 2005, a total of 24 consecutive patients with PSHP were retrospectively reviewed. Before January 2000, there were 13 patients who were subjected to the treatment strategy of initial tube thoracostomy and underwent operation if the condition deteriorated or later complications occurred (group T). Under this strategy, all of these patients later required operations. After January 2000, another 11 patients were treated with VATS as soon as their condition stabilized after tube thoracostomy and resuscitation (group V). The data for the two groups were compared: sex, age, involved side, initial heart rate (HR) and mean blood pressure (BP), initial hemoglobin (Hb), preoperative blood loss, operating time, amount of blood transfusion, period of chest tube drainage (POD), length of hospital stay (LOS), complications, and length of follow-up. RESULTS: The sex, age, involved side, and the initial HR, BP, and Hb of the two groups were similar. The patients of group V had a significantly longer operating time [group V, 111 minutes (mean); group T, 85 minutes, P = 0.002]; less preoperative blood loss (group V, 946 ml; group T, 1687 ml, P = 0.003); less blood transfusion (group V, 465 ml; group T, 1044 ml, P = 0.002); shorter POD (group V, 4 days; group T, 7 days, P = 0.011); and shorter LOS (group V, 5 days; group T, 10 days, P = 0.002). No mortality or recurrence was noted in the entire series. CONCLUSIONS: Our study suggests that surgery should be undertaken for PSHP as soon as possible after the clinical condition has stabilized. Under this strategy, VATS is an acceptable approach. It allows a shorter hospital stay and is exempt from unnecessary blood transfusion. Later complications, such as empyema and impaired lung reexpansion, can also be avoided.

Treatment of palmar hyperhidrosis: T(4) level compared with T(3) and T(2).

OBJECTIVE: The aim of this study was to compare the outcomes of 3 different levels of sympathectomy. SUMMARY BACKGROUND DATA: Most surgeons still perform T(2) or T(2-3) sympathectomy for palmar hyperhidrosis, but both these treatments can cause severe side effects. Some recent articles have advocated T(4) sympathectomy and obtained satisfactory results. METHODS: Between January 2000 and August 2004, 234 records of patients treated for palmar hyperhidrosis were retrospectively reviewed. Of them, 86 patients were treated with endoscopic thoracic sympathectomy of T(2) (ETS(2)), 78 patients with ETS(3), and 70 patients with ETS(4). Follow-up data were collected using a telephone questionnaire with a scoring system. Multiple linear regressions were used to model markers for degree of satisfaction and severity of compensatory sweating (CS), including descriptive data, level of sympathectomy, clinical outcomes, and postoperative complications. RESULTS: Mean follow-up was 47.1 +/- 17.2 months. All 3 levels of sympathectomy could have achieved comparable improvement of palmar hyperhidrosis (P = 0.162). However, 88.5% of the patients noticed CS. Patients with ETS(4) presented the lowest incidence of CS (P = 0.030), had the least severity of CS (beta = -1.537, P = 0.002), and felt the least palmar overdryness (P < 0.001). None expressed regret for the procedure in the ETS(4) group (P = 0.022). Being obese did not increase the incidence of CS, but the severity of CS was directly related to body mass index (beta = 0.917, P < 0.001). The patients would be more satisfied if the severity of CS was minimal (beta = -0.185, P = 0.002). The degree of satisfaction may decrease with time (beta = -0.025, P = 0.003) and was lower when their palms were overdry (beta = -1.463, P < 0.001). CONCLUSIONS: Different from the current procedure of T(2) or T(3) sympathectomy for palmar hyperhidrosis, T(4) sympathectomy would be a better and more effective procedure with minimal long-term complications.