THORACOSCOPY: A USEFUL DIAGNOSTIC AND THERAPEUTIC PROCEDURE

This study was performed to review the place of thoracoscopy in the diagnosis and treatment of intrathoracic disorders. A combined retrospective and prospective review was undertaken of the first 50 patients who undenvent diagnostic or therapeutic thoracoscopy in Ballarat. Recurrent pleural effusions (29), pneumothoraces (7), or diffuse or localized lung disease (14) were the main indications. Thoracoscopy was performed in conjunction with pleural or lung biopsy, excision of cysts, or pleurodesis. Patient tolerance of the procedure was excellent with minimal postoperative pain. Operative morbidity rates were very low (< 4%). The low mortality rate was related to underlying disease processes. Hospital stay was short. The long-term results were excellent. Adequate tissue was obtained on biopsy in most cases, cure achieved for pneumothoraces, and permanent palliation after talc pleurodesis for malignant effusions approached 80%.     

Non-surgical treatment for post pneumonectomy empyema

We describe an alternative treatment for postpneumonectomy empyema in patients for which Claggett procedure is inappropriate. During the years 1990-2002 eight patients with postpneumonectomy empyema were treated by continuous soft tube thoracostomy, intrapleural fibrinolysis and antibiotics. The medical records of these patients were reviewed retrospectively. The procedure was well tolerated by all patients and there were no significant complications during the treatment period. One patient died 9 months postpneumonectomy due to metastatic disease. The remaining patients have successfully completed the treatment with no recurrence of empyema. Continuous soft tube drainage with intrapleural fibrinolysis and antibiotics is a safe treatment for postpneumonectomy empyema in patients who are not appropriate candidates for operative management.     

Talc poudrage in the treatment of spontaneous pneumothoraces in patients with cystic fibrosis.

As patients with cystic fibrosis live longer, spontaneous pneumothoraces are seen with increasing frequency. Severe underlying pulmonary disease in these patients makes them particularly susceptible to life-threatening respiratory distress. Several modalities, including chemical sclerosis and open thoracotomy with pleurectomy, have been used to treat pneumothoraces in these patients. In the past 4 years, pneumothoraces in five patients (ages 9-22 years) with cystic fibrosis have been treated with thoracoscopy and talc poudrage. All procedures were performed under either regional or general anesthesia, depending on the age of the patient. Thoracoscopy was performed with a rod lens system and a 5.5-mm trocar, using biopsy forceps to lyse pleural adhesions, all of which ensures access to the entire pleural surface. United States Pharmacopeia-certified talc was insufflated to cover the entire pleural surface. There were no complications, and the patients had minimal pleural pain. Follow-up ranged from 6 months to 4 years. No patient has had a recurrent pneumothorax on the treated side. Thoracoscopy with talc poudrage is a preferable alternative to chemical sclerosis or thoracotomy for treating pneumothoraces in patients with cystic fibrosis. The procedure may be performed under regional anesthesia and allows rapid and complete sclerosis of the pleural cavity.     

Long-term results after tetracycline pleurodesis in spontaneous pneumothorax.

From 1979 to 1988 483 patients were admitted with primary spontaneous pneumothorax. All patients underwent thoracoscopy to identify the cause of pneumothorax. Chemical pleurodesis with instillation of tetracycline was performed if cysts less than 2 cm in diameter were found. If larger cysts were identified the patient underwent thoracotomy. In 93 patients with cysts larger than 2 cm the recurrence rate after thoracotomy was 4%. In 390 patients treated with intrapleural instillation of tetracycline, the recurrence rate was 16%. Fifty percent of the recurrences occurred within 30 days. The cause of recurrence in 42 patients (69%) was cysts missed at the initial thoracoscopy. This study has demonstrated that thoracoscopy is a reliable and safe method for selection of patients for chemical pleurodesis. It is, however, necessary that the thoracoscopy is meticulous to avoid recurrence from missed cysts.     

Video-Assisted Thoracic Surgery: Applications and Outcome

Thoracoscopy has been revived and expanded by recent improvements in endoscopic technology. The enhanced application and outcome of VATS (video assisted thoracic surgery) was retrospectively studied. Between 1992 and 1995, 82 patients underwent diagnostic thoracoscopy or interventional VATS. Indications included: shortness of breath with nonspecific x-ray abnormality (45%), pulmonary nodule (25%), pleural effusion/empyema (21%), pneumothorax (14%), and hemoptysis, chronic cough or lung consolidation (5%). Sixty-six (83%) of the procedures were completed thoracoscopically. Eight procedures (10%) required addition of a utility mini-thoracotomy and 6 procedures (7%) were converted to formal thoracotomy. Specific diagnostic and/or therapeutic applications of VATS included: inspection; lysis of adhesions; stapling of blebs; biopsy of lung, pleura, or mediastinal structures; drainage and decortication of empyema; mechanical and chemical pleurodesis; wedge resection; and segmental resection.Diagnosis was established and/or treatment completed in 95% of cases. Pathologic diagnoses included: interstitial pneumonitis (22%), cancer (19%), bullous disease (15%), cocci nodule (9%), and other (18%). There were twentytwo complications (28.9%) and four deaths (4.8%). All four deaths were from causes unrelated to the surgery. The most common complications were: residual pneumothorax or hydrothorax (7), failed pleurodesis (3), and prolonged incisional pain (2).The advantage of reduced chest wall and muscle trauma utilizing VATS as opposed to traditional thoracotomy translates to less patient discomfort. The excellent magnified visualization afforded by VATS offers the opportunity to successfully conduct diagnostic and therapeutic interventions in the chest with equal or better visibility. Our findings suggest that the applicability and success of VATS is greatly expanding and its complication rate is less or, at worst, comparable to traditional thoracotomy.     

Endoscopy assisted microthoracotomy: initial experience.

BACKGROUND: Although thoracoscopy has been used for diagnostic and minor therapeutic procedures for many years, there have been few reports of its use in performing major intrathoracic procedures, which have traditionally required formal thoracotomy. METHODS: Twenty one patients (M:F 1.2:1; mean (SD) age 47.1 (18.8), range 17-75 years) underwent endoscopic intrathoracic surgery. Eight had unidentified peripheral masses on the chest radiograph, eight required lung biopsy, and five had recurrent or persisting pneumothoraces. Under general anaesthesia a laparoscope attached to a video monitor was introduced into the chest. One or two additional stab incisions were made as needed for the introduction of standard surgical or endoscopic instruments and staplers. RESULTS: There were no complications or deaths, though one patient developed a second pneumothorax seven days after endoscopic pleurectomy, necessitating open pleurodesis. All patients were discharged home from two to six days after surgery (mean (SD) 3.7 (1.2) days). CONCLUSION: Endoscopic thoracic surgery is a safe and useful technique for certain cases. It merits further investigation and assessment.     

Diagnosis and removal of foreign bodies of the thoracic cavity using thoracoscopy

The author analysed the use of thoracoscopy in 12 patients with radiopaque and radiolucent foreign bodies in the pleural cavity, lung, mediastinum, myocardium, and diaphragm. The indications for the examination were specified: (1) foreign body in the pleural, cavity or its existence suspected; (2) indistinct character of an intrathoracic foreign body and injury inflicted by it to the viscera; (3) specification of surgical tactics and method for removal of the foreign body and rational surgical approach. Thoracoscopy made it possible to detect not only foreign bodies of different character, but the damages caused by them to the viscera, and the complications. Foreign bodies were removed during thoracoscopy in two thirds of cases.     

Thoracoscopic Surgery for Pulmonary Tuberculosis

Tuberculosis historically was a major impetus for the development of thoracic surgery, and it remains a serious health problem of global proportion. Thoracoscopy was first introduced at the turn of this century for closed chest adhesiolysis as an adjunct to collapse therapy for treatment of tuberculosis. This indication became obsolete with the discovery of streptomycin during the 1940s; and for a long time since then thoracoscopy was used only sporadically for the diagnosis of pleural disease. However, over the last few years, modern video-assisted thoracoscopic surgery (VATS) has provided a new approach to the management of pulmonary tuberculosis. Over the last 5 years we have used VATS for diagnosis or treatment (or both) of 62 patients with pulmonary tuberculosis, including 20 pleural biopsies, 8 decortications, 17 wedge lung resections, 8 drainages of empyema, and 9 lobectomies. There was no surgical mortality, and complications were few. We conclude that VATS provides a safe, effective diagnostic modality (pleural biopsy, wedge resections) and therapeutic modality (decortications, drainage of empyema) for selected patients with pulmonary tuberculosis.     

Thoracoscopy in children.

Dissatisfied with standard techniques for pulmonary diagnosis in children, we have evaluated the usefulness of thoracoscopy for diagnosis of intrathoracic pathology. Between July 1, 1975, and May 1, 1978, 65 thoracoscopy procedures have been performed in 57 children at the University of Florida. Thirty-four procedures were performed in immunosuppressed patients to rule out Pneumocystis carinii pneumonia. Twenty of these patients were proven to have Pneumocystis pneumonia, a diagnostic accuracy of 100%. Twelve nonimmunosuppressed patients underwent thoracoscopy for the diagnosis of persistent pulmonary infiltrates with a 100% diagnostic accuracy. Fifteen procedures were performed for the diagnosis of intrathoracic tumors. In two patients, previously unsuspected areas of involvement were encountered while in two patients false-negative biopsies were obtained. Four patients underwent therapeutic thoracoscopy. In three small infants, unsuccessful attempts were made to unroof pulmonary cysts through the thoracoscope and one patient underwent a talc poudrage. Thoracoscopy has proven to be a safe and rapid procedure which may be performed under local anesthesia without need for endotracheal intubation. In patients with pulmonary infiltrates, the accuracy has been 100%. The capability of viewing the entire hemithorax has proven valuable in evaluating children with intrathoracic tumors. Complications have included pneumothorax in six patients and bleeding in two.     

Thoracoscopic ablation of blebs using PDS-endoloop in recurrent spontaneous pneumothorax.

Thoracoscopy has specific advantages over traditional open thoracotomy, including shorter hospitalization, decreased recovery time, and an earlier return to the work force. Thoracoscopy and bleb ablation using sophisticated lasers has been successful in treating spontaneous pneumothorax. We have recently completed thoracoscopy bleb ablation with PDS Endoloop (Polyclioxanone, Ethicon, Inc., Somerville, NJ, U.S.A.) and pleurodesis in a patient with a recurrent spontaneous pneumothorax. The chest tube was removed and the patient discharged on the 3rd postoperative day. He returned to work on the 7th postoperative day. This new procedure can be used on selected patients with small blebs.     

Early and late outcome after diagnostic thoracoscopy and talc pleurodesis.

Although thoracoscopy is now recognized to be of both diagnostic and therapeutic value, the risks of this procedure have not been fully addressed. We retrospectively reviewed our experience with 100 patients who underwent 110 thoracoscopies during the period January 1989 to February 1991. Sixty-five men and 35 women (ratio of 1.9:1) underwent thoracoscopy using general anesthesia and intubation with a double-lumen endotracheal tube. The mean age was 64.2 +/- 11.6 years (range, 13 to 85 years). The diagnosis was established in 48 (85.7%) of the 56 patients with undiagnosed pleural effusions. Forty-four patients were referred for therapeutic thoracoscopic talc pleurodesis. Pleurodesis was successful in 42 patients (95.5%). Four patients (4%) had five postoperative complications (two bronchopleural fistulas, two chest infections, and one arrhythmia). Five patients (5%) died after thoracoscopy; mean age was 67.8 +/- 8.1 years (range, 55 to 77 years). The causes of death were cardiac arrest in 2, respiratory failure in 1, and malignant cachexia in 2. The findings of this study confirm that thoracoscopy can achieve high rates of diagnostic and therapeutic success but is not without attendant mortality in a high-risk patient population.     

Talc pleurodesis: a new technique

Pleurodesis is a commonly used option in the management of malignant pleural effusion. Although several chemical agents are used talc has only recently been advocated as the sclerosing agent of choice. Talc can be administered via open thoracotomy or tube thoracostomy, but thoracoscopy offers an excellent alternative to these approaches. We describe a new technique of thoracoscopically applied talc pleurodesis that is easy, inexpensive, and reliable.     

Thoracoscopic pleurodesis in malignant pleural effusions

We performed retrospectively study on 136 thoracoscopies done in our clinic in the period January 2000 and December 2004. We reviewed 136 thoracoscopies, 71 patients were male and 65 were female (mean age 58.4 years). Straw colored effusions were present in 78 cases (57%) and hemorrhagic in 58 cases (43%). The surgical procedure consist in diagnostic of thoracoscopy with drainage of pleural effusion, multiply pleural biopsy, pleurodesis and continuous pleural drainage. In our study, the talc powder (5g) was successfully as sclerosing agent. The primary tumor was: lung-63 (46%), breast-26 (19%), mesothelioma-21 (15.5%), stomach-3, ovarian-3, prostate-3, colon-2, lymphoma-1, leukemia-2, plasmocytoma-1 and unknown primary tumor in 11 cases (8%). Adverse effects included-chest pain-35 cases (25%), fever-20 cases (15%), empyema-6 cases (4.5%), prolonged air leak-5 cases (4%), pulmonary infection-2 cases, acute respiratory failure-1 case, malignant invasion of scar-1 patient. For statistical analysis, the success of talc pleurodesis was defined as the absence of pleural fluid on the follow-up chest radiographs. Pleurodesis was successful in 125 cases (92%) of the patients after 1 month-follow-up. Thoracoscopic talc pleurodesis is a safe, economical and effective treatment for malignant pleural effusion.     

Benefits of early aggressive management of empyema thoracis

BACKGROUND: The end-target of the management of thoracic empyema is to obtain early rehabilitation by re-expansion of the trapped lung resulting from intrapleural infected material. Our aim was to shorten the hospitalization time and to prevent a possible thoracotomy by using video-assisted thoracoscopy initially. METHODS: Seventy patients with parapneumonic empyema were prospectively studied between January 1997 and June 2004. The patients were randomly divided into two groups. In group I (n = 35 patients), a chest tube was inserted into the patients after pleural content was evacuated and fibrins were debrided using video-assisted thoracoscopy. In group II (n = 35 patients), tube thoracostomy was carried out without using a video-assisted thoracoscope. Both groups were compared in terms of hospitalization time, open surgery for decortication and complications. RESULTS: There was no statistically significant difference between the groups from the point of view of age and sex (P > 0.05). In group I, 17.1% of the patients underwent open decortication, whereas in group II, 37.1% of the patients underwent the same procedure (P < 0.05). Whereas average hospital stay in group I was 8.3 days (range, 7-11 days), it was 12.8 days in group II (range, 10-18 days; P < 0.05). There was one bronchopleural fistula in group I, and there was one bronchopleural fistula and one death in group II. CONCLUSION: Video-assisted thoracoscopic evacuation and chest tube insertion in situ is a new therapeutic approach for pleural empyema that shortens hospital stay and reduces the necessity of open decortication.     

Thoracoscopic treatment of spontaneous pneumothorax in children

Background/purpose

This study describes the authors experience and results with thoracoscopic treatment of spontaneous pneumotrorax (SP) in 22 children.

Methods

A total of 32 thoracoscopic procedures were performed in 22 children. The patients ranged in age from 9 to 21 years at the time of their first thoracoscopy. SP was primary in 9 and secondary in 13 patients. Pleurodesis was performed in all thoracoscopies using talc in 28 and pleural abrasion in 4 procedures. In 2 of these, apical pleurectomy was added to abrasion. Blebectomy was the additional surgical procedure associated with pleurodesis in 4 patients.

Results

Thoracoscopy usually was performed with the patient under general anesthesia. In children with severe respiratory insufficiency, regional anesthesia was used. The mean operative time was 42.6 minutes (range, 8 to 114 minutes). The mean time of postoperative chest tube drainage was 4.6 days (range, 2 to 12 days). Three patients with cystic fibrosis had prolonged air leak lasting longer than 7 days after thoracoscopy. None of them required an additional surgical intervention, and the air leak ceased in 8, 8, and 12 days with continuous suction. One patient required a repeat thoracoscopy for bleeding from an intercostal artery on postoperative day one. The mean follow-up was 4 years (range, 2.5 months to 14 years). There have been 2 partial recurrences (6.25%), both in patients with secondary SP, which were treated by a repeat thoracoscopy and talc pleurodesis.

Conclusions

Thoracoscopic treatment of SP is safe and effective in children. It can be performed under regional anesthesia also in children with severe respiratory insufficiency. Because the complications and recurrences are encountered more frequently in children with an underlying lung disease, special care in surgical manipulation is required in this subgroup of patients with SP.     

The role of thoracoscopy in the treatment of pleural empyema in children

Background The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently, thoracoscopy often is used to treat this disease in some thoracic surgery centers. This report aims to present the authors’ experience with the treatment of pleural empyema and the benefits of thoracoscopy. Methods From 1997 to 2005, 49 children with a diagnosis of pleural empyema were treated by means of thoracoscopy in the authors’ department. The study group consisted of 21 girls and 28 boys, ages 1 to 17 years (mean age, 9.2 years). Thoracoscopic cleaning and drainage of the pleural cavity was performed for all the patients. Results Intraoperatively, stage I empyema was recognized in 7 children (14.3%), stage II in 30 children (61.2%), and stage III in 12 children (24.5%). Very good results were obtained for all the patients. There were no intra- or postoperative major complications. The drainage time was less than 5 days for 63.3% of the children. In the remaining group of patients, drainage exceeded 8 days only for 16.3%. The postoperative time was short. Emptying of the pleural cavity and full lung decompression were achieved in all cases. In four cases, pleural biopsy showed TB, which enabled early proper treatment. Conclusions Thoracoscopy can offer good visualization and cleansing of the empyema chambers, establishing efficient drainage even for patients with advanced stages of pleural empyema. Thoracoscopy enables collection of material not only for bacteriologic, but also for histopathologic examination. The method is minimally invasive, and risk for complication is comparable with that for classical thorax drainage.     

Thoracoscopic retrieval of intra-parenchyamal foreign body of lung

Thoracoscopy is an innovative procedure. We have retrieved intraparynchymal lung foreign body by thoracoscopy. Intraoperative imaging by ‘C’ arm facilitated the procedure. Thoracoscopy is a therapeutic option of choice for projectile thoracic injuries, provided patient is hemodynamically stable.     

Thoracoscopic palliative treatment of malignant pleural effusions

Background The aim of this study was to analyze the results of pleurodesis for malignant pleural effusion performed by surgeons. Patients and methods A series of 273 patients with malignant pleural effusion underwent thoracoscopy with the aim of performing a palliative pleurodesis. There were 94 males (34.4%) and 175 females (64.1%), ranging in age from 15 to 94 years (mean age: 60.6 years). The effusion was on the right side in 136 patients (49.8%), on the left side in 110 (40.3%), and bilateral in 27 (9.9%). Thoracoscopy was performed under general anaesthesia in all patients. Pleural biopsy was performed in two thirds of the patients (70.7%). Pleurodesis was produced by instillation of 5g of sterile asbestos-free talc; the chest tube was left in place a minimum of 3 days. It was removed when fluid drainage was less than 200 ml/24 h. Patients were usually discharged the day after chest tube removal. Results There was no intraoperative mortality. Two patients (0.7%) had intraoperative complications; 17 (6.2%) underwent a bilateral pleurodesis, and 10 (3.7%) had a pericardiopleural window. In 32 patients (11.7%) no pleurodesis was done, either because the lung did not properly re-expand (5.2%), or because of suspected infection, e.g., false membranes (1.9%), or because of multiple adhesions (4.6%). Finally, only 241 patients (88.3%) had a talc poudrage at the time of thoracoscopy. Duration of postoperative pleural drainage ranged between 1 and 11 days (mean: 3.64 days). The postoperative hospital stay ranged from 2 to 21 days (mean: 7.1 days). Pleural empyema occurred in 4 patients (1.5%) and was lethal in one patient. The mean follow-up period was 8.39 (7.2 months, and 172 patients had regular follow up. In this group, there were 24 recurrences (14%), 12 of which were treated by repeat pleurodesis. The results were very good in 133 patients (77.3%), acceptable in 35 patients (20.3%), and there was a failure in 4 patients (2.4%). Conclusions Results of surgical thoracoscopy for malignant pleural effusion are good, with low morbidity. However, in debilitated patients, bedside talc slurry may be preferable. Presented at the 13th Congress of the EAES (European Association for Endoscopic Surgery), Venice, June 2005.     

Thoracoscopy in children: anaesthesiological implications and case reports

AIM: Videoassisted thoracic surgical technique in children is being used with increasing frequency for an extensive variety of diagnostic and therapeutic procedures. The aim of the study was to assess respiratory, cardiocirculatory and body temperature changes in children undergoing thoracoscopy and to identify if the trend of such changes was modifiable by factors such as lung exclusion, length of the thoracoscopy and preoperative respiratory compromise. METHODS: A total of 50 patients (38 boys and 12 girls) undergoing general anaesthesia for diagnostic and therapeutic thoracoscopic procedures were analysed. The values of the monitored parameters were compared at 6 specific times: T1 - at the end of anaesthesia induction (considered the basal level); T2 - after lateral position; T3 - before pleural CO2 insufflation; T4 - 10 min after pleural CO2 insufflation; T5 - before pleural deflation; T6 - 10 min after pleural deflation. RESULTS: All patients tolerated the thoracoscopy well, without intraoperative complications. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly lower, and end-tidal CO2 (PETCO(2) significantly higher during thoracoscopy. Body temperature (BT) had a statistically significant reduction during thoracoscopy and after pleural deflation. During one-lung ventilation the PETCO(2) increased compared to two-lung ventilation with intrapleural insufflation, while during two-lung ventilation with intrapleural insufflation SBP and DBP decreased compared to one-lung ventilation. The length of the thoracoscopy increased the PETCO(2) and reduced the BT. The preoperative respiratory compromise increased the PETCO(2). CONCLUSIONS: Although thoracoscopy in children brings about certain respiratory, cardiocirculatory and body temperature changes, it is nevertheless a safe and efficient surgical technique.     

Postpneumonectomy empyema. The role of intrathoracic muscle transposition

Forty-five patients (36 male and nine female) were treated for postpneumonectomy empyema. All were initially managed with the first stage of the Clagett procedure (open pleural drainage). In 28 patients with associated bronchopleural fistula the fistula was closed and reinforced with muscle transposition at the time of open drainage. Seven patients had multiple flaps. The serratus anterior muscle was transposed in 28 patients, latissimus dorsi in 11, pectoralis major in four, pectoralis minor in one, and rectus abdominis in one patient. After the fistula was closed and the pleural cavity was clean, the second stage of the Clagett procedure (obliteration of the pleural cavity with antibiotic solution and closure of the open pleural window) was done. The number of operative procedures ranged from 1 to 19 (median 5.0). Length of hospitalization ranged from 4 to 137 days (median 34.0 days). There were six operative deaths (mortality rate 13.3%), none in the patients who had both stages of the Clagett procedure. Follow-up of the 39 operative survivors ranged from 2.1 to 90.2 months (median 21.8 months). Eighty-four percent of patients in whom the Clagett procedure was completed (26/31) had a healed chest wall with no evidence of recurrent infection. The bronchopleural fistula remained closed in 85.7% of patients (24/28). There were 19 late deaths, none related to postpneumonectomy empyema. We conclude that the Clagett procedure remains safe and effective in the management of postpneumonectomy empyema in the absence of bronchopleural fistula and that intrathoracic muscle transposition to reinforce the bronchial stump is an effective procedure in the control of postpneumonectomy-associated bronchopleural fistula.