Minimal-invasive Thoraxchirurgie

Background

A fundamental argument against minimally invasive oncological chest surgery is the risk of overlooking pulmonary nodules due to a lack of intraoperative palpation. In the literature  this risk in the treatment of primary lung cancer is given as up to 8.4?% and as more than 15?% in the surgical treatment of pulmonary metastases.

Objective

The aim of this study was to evaluate if modern computed tomography (CT) is sensitive enough to replace intraoperative palpation and justify a minimally invasive approach.

Patients and methods

The medical records from 92 patients who underwent 95 open lung resections due to pulmonary malignancies from April 2010 through September 2011 at the Medical School Hannover were retrospectively analysed. A comparison was carried out between the lesions detected preoperatively by CT and those removed during surgery and histologically confirmed as being malignant. Patients with more than five nodules suspected of being malignant in the preoperative CT scan were excluded.

Results

According to the final histopathological examination 125 malignant nodules were resected and 2 of these were not detected in the preoperative CT scan, which were performed in external hospitals with a slice thickness of 5 mm and 8 mm, respectively. This represents a sensitivity of 98?% for all CT scans in terms of detection of pulmonary nodules. With thin slice CT (slice thickness up to 1.5 mm) a sensitivity of 100?% was even achieved.

Conclusion

The results demonstrate that a high sensitivity of thin slice CT for detection of lung nodules can be achieved. Based on these results the categorical reservation with respect to thoracoscopic resection of pulmonary metastases should be reconsidered in suitable patients where a minimally invasive resection is possible. The extent of lymph node dissection is not influenced by these data. Further studies with larger sample sizes are warranted to confirm these results.

     

Accuracy of helical CT in the detection of pulmonary metastases: is intraoperative palpation still necessary?

Background

Pulmonary metastasectomy is well accepted in patients with isolated metastases from an extrathoracic malignancy. The standard approach involves careful intraoperative palpation of the lungs because more metastases are frequently found than were seen by preoperative conventional computed tomography (CT). Helical CT detects more nodules than conventional CT, raising the question of whether palpation of the lungs is still necessary if helical CT is used.

Methods

Retrospective review was done of medical records of patients undergoing metastasectomy with curative intent at the University of North Carolina (UNC) from 1999 to 2003. During this time at UNC, helical CT was routinely performed using a standardized technique, and all metastasectomy patients underwent manual lung palpation. The primary outcome measure of this study was whether malignant nodules (palpated, resected, and proven histologically) were reliably detected preoperatively by helical CT.

Results

Thirty-four patients were identified who underwent 41 cases of pulmonary metastasectomy with lung palpation. Our analysis revealed that in 22% (9/41), more malignant nodules were found intraoperatively than were detected by helical CT. Of 88 malignant intraparenchymal nodules, 69 were detected by helical CT (sensitivity 78%). Subset analyses of tumor histology, disease-free interval, the presence of a single lesion versus multiple lesions, the interval between the CT and metastasectomy, and the size of the largest lesion were unable to identify a cohort in which lung palpation was no longer needed after preoperative helical CT.

Conclusions

Despite the advent of helical CT, palpation of the lung is necessary if the goal is to resect all detectable disease.     

Intraoperative electromagnetic navigational bronchoscopic localization of small,deep, or subsolid pulmonary nodules

Background

Localizing small or deep pulmonary nodules or subsolid ground-glass opacities often is difficult during video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). This can result in larger resections or conversion to thoracotomy. The goal of this study is to evaluate the role of electromagnetic navigational bronchoscopic localization (ENBL) as a safe and accurate intraoperative method to localize small, deep, or subsolid nodules.

Localization of small pulmonary nodules for videothoracoscopic surgery

The aim of this study is to discuss and summarize the localization of small pulmonary nodules for video-thoracoscopic surgery. Thirty-eight patients were selected, 22 men and 16 women, and they underwent video-assisted thoracoscopic surgery resection for small pulmonary nodules: 28 patients for small solitary pulmonary nodules and 10 patients for multiple small pulmonary nodules. In all cases, resection of the nodules was successful. Localization methods included: (i) computed tomography (CT)-guided methylene blue labelling for preoperative localization; (ii) a high-quality chest CT scan for preoperative localization; (iii) visual exploration, digital palpation and 'instrumental' palpation to locate the nodule; and (iv) endosonographic inspections of intraoperative localization. Using a combination of CT scan, digital palpation, methylene blue labelling and endosonographic inspections, all nodules were successfully localized and resected without significant complications. Video-assisted thoracoscopic surgery is an effective approach but the small lung nodules (especially those less than 1.0 cm in diameter) localized at thoracoscopic resection must be treated carefully. Combined imaging and thoracoscopic techniques may help identify small nodules.     

Use of radiotracer labeling of pulmonary nodules to facilitate excisional biopsy and metastasectomy in children with solid tumors

Purpose

Excision of suspected pulmonary metastases in children is challenging in the setting of multiple nodules or nodules that are small, deep, or soft. This study describes preoperative technetium macro-aggregated albumin (Tc 99m MAA) localization of pulmonary lesions to aid in intraoperative identification and resection.

Preoperative radio-guided localization of lung nodules with I-125 seeds: experience with 32 patients at a single institution

 Open in a separate windowOBJECTIVESVideothoracoscopic visualization and/or palpation of pulmonary nodules may be difficult due to their location, small size or limited solid component. The purpose of this study is to present our experience with computed tomography (CT)-guided preoperative localization of pulmonary nodules by percutaneous marking with radio-labelled iodine-125 seeds.METHODSA total of 34 pulmonary nodules were marked under CT with the placement of 33 radio-labelled iodine-125 seeds in 32 consecutive patients.RESULTSAll patients underwent biportal video-assisted thoracic surgery (VATS) and in no case was conversion to thoracotomy necessary. A total of 88.2% of the lung nodules were successfully resected. In the remaining 11.8%, migration of the seed to the pleural cavity occurred, although these nodules were still resected during VATS. Of all the patients with pneumothorax after the marking procedure, only one required chest tube placement (3.1%). No major postoperative complications were observed.CONCLUSIONSPreoperative marking of pulmonary nodules with I-125 seeds under CT guidance is a feasible and safe technique that allows their intraoperative identification and resection.     

Successful thoracoscopic lung biopsy in children utilizing preoperative CT-guided localization

Background/Purpose: Although thoracoscopy in children is a well-accepted technique, there are limitations to this approach. Small lung nodules or those not located on the pleural surface often require an open thoracotomy. The purpose of this report is to evaluate the utility of computed tomography (CT) guided needle localization of lung nodules in children followed by thoracoscopic resection. Methods: From 1997 to 2000, 13 thoracoscopic procedures were performed on 12 children who presented with small pulmonary nodules ([lt ]1 cm) or nodules deep to the pleural surface. Preoperative needle localization was performed by injecting methylene blue under CT guidance. Patients then were taken directly to the operating room for thoracoscopic resection. Results: All 13 procedures were completed successfully thoracoscopically. Twelve yielded diagnostic pathologic findings as well as therapeutic resections in 7. All patients underwent extubation in the operating room, and chest tubes were removed within 36 hours. No thoracotomies were performed, and there were no complications. Conclusions: Preoperative localization utilizing CT guidance is safe and beneficial in children with pulmonary nodules less than 1 cm in size and those located deep to the pleural surface. This technique allows the surgeon to perform thoracoscopy for diagnosis and therapeutic resection of these lesions rather than submitting patients to the morbidity of a thoracotomy. J Pediatr Surg 37:970-973.     

Computed tomographic scan of the chest underestimates the number of metastatic lesions in osteosarcoma

Purpose

Survival in osteosarcoma correlates with complete resection of primary and metastatic disease. The feasibility of complete pulmonary metastasectomy using thoracoscopy has been raised. Because palpation is not possible, minimally invasive techniques require preoperative radiological enumeration and localization of metastases not presenting at the lung surface. We hypothesized that computed tomographic (CT) scanning underestimated the number of pulmonary metastases in these patients.

Methods

Institutional review board approval was obtained. We determined the association between the number of lesions identified by CT scanning and the number of metastases found at thoracotomies for metastatic osteosarcoma from May 1996 to October 2004. Correlations between CT findings and pathology results were computed using the Kendall τ-b correlation coefficient. Depth, in millimeters, from the pleural surface was measured for those lesions seen on CT scan.

Results

We analyzed 54 consecutive thoracotomies performed in 28 patients for whom complete imaging was available. Computed tomographic scanning was performed a median of 20 days before thoracotomy (range, 1-85 days). Correlation between the number of lesions identified by CT and the number of metastases resected at surgery was poor, with a Kendall τ-b correlation coefficient of 0.45 (P < .001). In 19 (35%) of 54 thoracotomies, CT scanning underestimated the number of pathologically proven, viable and nonviable metastases found by the surgeon. Accounting for viable metastases only, correlation between the number of lesions identified by CT and the number of metastases resected at surgery was 0.50 (P < .001), and CT scanning underestimated the number of viable metastases present in 14 (26%) of 54 thoracotomies. Many lesions (32%) were pleural-based, but nearly half (47%) were 5 mm or deeper from the pleural surface of the lung.

Conclusions

Even in the era of modern CT scanning, only a very rough correlation exists between CT findings and the number of lesions identified at thoracotomy. In more than one third of thoracotomies in our series, metastases would have been missed by any tactic besides manual palpation of the lung during open thoracotomy. Minimal access procedures should not be the approach of choice if the goal is resection of all pulmonary metastases in osteosarcoma.     

Indeterminate Pulmonary Nodules at Colorectal Cancer Staging: A Systematic Review of Predictive Parameters for Malignancy

Background

This study aimed to estimate the prevalence of indeterminate pulmonary nodules and specific radiological and clinical characteristics that predict malignancy of these at initial staging chest computed tomography (CT) in patients with colorectal cancer. A considerable number of indeterminate pulmonary nodules, which cannot readily be classified as either benign or malignant, are detected at initial staging chest CT in colorectal cancer patients.

Methods

A systematic review based on a search in EMBASE, Medline, the Cochrane library and science citation index, PubMed databases, Google scholar, and relevant conference proceedings was performed in cooperation with the Cochrane Colorectal Cancer Group.

Results

A total of 2,799 studies were identified, of which 12 studies met the inclusion criteria. The studies primarily consisted of case series and included a total of 5,873 patients. Of these patients, 9 % (95 % confidence interval [95 % CI] 8.9–9.2 %) had indeterminate pulmonary nodules at chest CT, of which 10.8 % (95 % CI 10.3–11.2 %) turned out to be colorectal cancer metastases at follow-up. Generally, regional lymph node metastasis, and multiple numbers of indeterminate pulmonary nodules were reported to predict malignancy, whereas calcification of the nodules indicated benign lesions.

Conclusion

It was found that 1 in 100 colorectal cancer patients subjected to preoperative staging chest CT will have an indeterminate pulmonary nodule that proves to be metastatic disease. Such a low risk suggests that indeterminate pulmonary nodules should not cause further preoperative diagnostic workup or follow-up besides routine regimens.     

Methylene blue-stained autologous blood for needle localization and thoracoscopic resection of deep pulmonary nodules

Background/Purpose: Video-assisted thoracoscopic surgery (VATS) has used a variety of preoperative techniques to localize deep pulmonary nodules including wires, plain methylene blue, colored collagen, indigo carmine, India ink, and barium. The authors describe their experience with a computed tomography (CT)[ndash ]guided localization technique using autologous blood stained with methylene blue. Methods: The authors reviewed retrospectively children who had pulmonary nodules localized using CT guidance with a mixture containing 3mL autologous blood stained with 0.3mL methylene blue. Nodules were resected by standard VATS technique. Postoperative chest tube drainage was performed selectively. Results: Nineteen procedures were performed in 17 children (average age, 11 years). Operating time (range, 21 to 171 minutes) varied depending on the number of nodules resected. All resections were diagnostic, and 80% represented malignancy. Lesions averaged 0.9 cm in size (range, 0.3 to 3 cm) with an average pulmonary depth of 0.8 cm (range, 0.1 cm to 1.8 cm). One patient required conversion to an open thoracotomy because of malfunction of the endoscopic stapler. Forty percent of the children received chest tubes, and 53% were discharged home the same day. Conclusion: VATS diagnostic resection of deep pulmonary nodules preoperatively localized with methylene blue stained autologous blood is safe and effective.     

Usefulness of robot-assisted thoracoscopic esophagectomy

Objectives

We started robot-assisted thoracoscopic esophagectomy using the da Vinci surgical system from June 2010 and operated on 30 cases by December 2013. Herein, we examined the usefulness of robot-assisted thoracoscopic esophagectomy and compared it with conventional esophagectomy by right thoracotomy.

Methods

Patients requiring an invasion depth of up to the muscularis propria with preoperative diagnosis were considered for surgical adaptation, excluding bulky lymph node metastasis or salvage surgery cases. The outcomes of 30 patients who underwent robot-assisted surgery (robot group) and 30 patients who underwent conventional esophagectomy by right thoracotomy (thoracotomy group) up to December 2013 were retrospectively examined. Five ports were used in the robot-assisted thoracoscopic esophagectomy: 3rd intercostal (da Vinci right arm), 6th intercostal (da Vinci camera), 9th intercostal (da Vinci left arm), 4th and 8th intercostals (for assistance).

Results

There was no significant difference in patient characteristics. Robot group/right thoracotomy group: Operation time, 563/398 min; thoracic procedure bleeding volume, 21/135 ml; number of thoracic lymph node radical dissections, 25/23. Postoperative complications were recurrent nerve paralysis, 16.7/16.7%; pneumonia, 6.7%/10.0%; anastomotic leakage, 10.0/20.0%; surgical site infection, 0/10.0%; hospitalization, 17/30 days. For the robot group, the operation time was significantly longer, but the amount of intraoperative bleeding and postoperative hospitalization were significantly reduced.

Conclusions

Robot-assisted thoracoscopic esophagectomy enables delicate surgical procedures owing to the 3D effect of the field of view and articulated forceps of the da Vinci. This procedure reduces bleeding and postoperative hospitalization and is less invasive than conventional esophagectomy by right thoracotomy.

     

Surgical management and outcome of osteosarcoma patients with unilateral pulmonary metastases

Purpose

The surgical management of osteosarcoma patients with unilateral pulmonary nodules is controversial. The authors reviewed their institutional experience to evaluate the incidence of occult contralateral metastases.

Methods

Data were obtained retrospectively on all consecutive osteosarcoma patients from 1980 to 2002. Eighty-four patients with pulmonary nodules were identified. Forty-one had bilateral disease, and 43 had unilateral involvement by computed tomography (CT) scan.

Results

All 43 patients with unilateral nodules underwent ipsilateral thoracotomies. Fifteen patients had negative exploration findings, and only 1 had pulmonary relapse. Of the 28 patients with metastases confirmed at initial thoracotomies, 14 had extensive pleural or extrapulmonary disease at initial thoracotomy followed by disease progression. The other 14 are separated into early versus late metastases, using 2 years from diagnosis as the cutoff point. Seven of the 9 (78%) patients with early metastases had or subsequently had contralateral disease; 6 were identified at staged contralateral thoracotomy and 1 had relapsed in the unexplored lung a year later. Only 1 of the 5 patients with late unilateral metastases had relapse in the contralateral side.

Conclusions

Our data indicate that there is a high rate of contralateral involvement in osteosarcoma patients with unilateral nodules diagnosed by CT scan. Staged bilateral thoracotomies should be considered in osteosarcoma patients presenting with unilateral pulmonary disease on imaging studies within 2 years of diagnosis.     

Usefulness of Contrast-Enhanced Intraoperative Ultrasonography (CE-IOUS) in Patients with Colorectal Liver Metastases after Preoperative Chemotherapy

Aims

The aim of this study was to evaluate the ability of contrast-enhanced intraoperative ultrasonography to detect colorectal liver metastases after preoperative chemotherapy compared with intraoperative ultrasound and preoperative imaging techniques.

Methods

From January 2010 to December 2011, 28 patients with colorectal liver metastases underwent intraoperative ultrasonography and contrast-enhanced intraoperative ultrasonography during hepatectomy following preoperative chemotherapy. The findings were compared to preoperative imaging using contrast-enhanced ultrasonography, computed tomography, magnetic resonance imaging, and/or fluorodeoxyglucose positron emission tomography.

Results

Preoperative imaging techniques detected 58 metastatic lesions in 28 patients. In 32 % of patients (n?=?9), intraoperative ultrasound detected 24 missed hepatic nodules. In 14 % of patients (n?=?4), contrast-enhanced intraoperative ultrasonography detected an additional six nodules and change in operative management occurred in 18 % of patients. Using univariate analysis, we found three factors significantly related to detection of additional metastases with contrast-enhanced intraoperative ultrasonography: three or more metastases before chemotherapy (p?=?0.047), resolution of at least one metastasis (p?=?0.011), and small liver metastases (largest lesion size ≤20 mm) after chemotherapy (p?=?0.007).

Conclusion

In patients undergoing surgery for colorectal liver metastases after chemotherapy, contrast-enhanced intraoperative ultrasonography improved both the sensitivity of intraoperative ultrasonography to detect liver metastases and the R0 hepatic resection rate.     

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience

Purpose

Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery.

Methods

We defined “unexpected intraoperative bleeding” as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels.

Results

Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different.

Conclusions

The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

     

Positive margins after breast-conserving therapy: localization technique or tumor biology?

Background

The relative contributions of patient and tumor factors versus radiologic localization technique to the rates of inadequate margins of excision in breast-conserving therapy have not been defined.

Methods

Patients undergoing breast-conserving therapy were studied. Margins less than 2 mm from tumor were considered inadequate.

Results

Of 539 patients, 31% were guided by palpation and 69% were guided by preoperative radiologic localization. The palpation-guidance patients had larger tumors (P < .0001) and more nodal metastases (P = .0005). The rates of inadequate margins were 10% for palpation-guided patients and 11% for radiologic-localization patients (P = .53). The 3-year rates of local recurrence were .7% for palpation-guided patients and 1.8% for radiologic-guided patients (P = .5).

Conclusions

Patient, tumor, and intraoperative pathologic factors, not just localization device shortcomings, produce inadequate margins of excision in breast-conserving therapy. A reasonable expected rate of inadequate margins owing to patient and tumor factors is 10%. Quality improvement for margin management must focus on intraoperative assessment of margins, especially for patients with identified risk factors, in addition to improving localization technique.     

Thoracoscopic segmentectomy for treatment of congenital lung malformations

Purpose

Congenital lung malformations (CLM) predispose patients to recurrent respiratory tract infections and pose a rare risk of malignant transformation. Although pulmonary lobectomy is the most common treatment of a CLM, some advocate segmental resection as a lung preservation strategy. Our study evaluated lung-preserving thoracoscopic segmentectomy as an alternative to lobectomy for CLM resection.

Methods

We conducted a retrospective review of patients who underwent thoracoscopic segmentectomy for CLM from 2007 to 2010.

Results

Fifteen patients underwent thoracoscopic segmentectomy for CLM. There were five postoperative complications: three asymptomatic pneumothoraces and a small air leak that resolved without intervention. One patient developed a bronchopulmonary fistula requiring thoracoscopic repair. At follow-up, all patients are asymptomatic. One patient has a small amount of residual disease on postoperative computed tomography (CT), and re-resection has been recommended.

Conclusions

Thoracoscopic segmentectomy for CLM is a safe and effective means of lung parenchymal preservation. The approach spares larger airway anatomy and has a complication rate that is comparable with that of thoracoscopic lobectomy. Residual disease can often only be appreciated on postoperative CT scan and may require long-term follow-up or reoperation in rare cases. This lung preservation technique is best suited to smaller lesions.     

胸腔镜肺段切除术的临床结果分析

目的 分析胸腔镜肺段切除术的临床结果,探讨胸腔镜肺段切除手术需要关注的临床问题,为更好开展胸腔镜肺段切除手术及减少围手术期并发症提供参考.方法 回顾性分析我科2017年10月至2019年12月开展的计划行胸腔镜肺段切除手术90例患者的临床资料,其中男35例,平均年龄(60.34±9.40)岁;女55例,平均年龄(56....     

Do characteristics of pulmonary nodules on computed tomography in children with known osteosarcoma help distinguish whether the nodules are malignant or benign?

Purpose

To determine if selected computed tomography (CT) characteristics of pulmonary nodules in pediatric patients with osteosarcoma can help distinguish the nodules as benign or malignant.

Methods

The institutional review board approved this HIPAA (Health Insurance Portability and Accountability Act-compliant, retrospective study of 30 pediatric osteosarcoma patients (median age 14 years, range 8-22) who underwent chest CT with resection of 117 pulmonary nodules from January 2001 to December 2006. Two pediatric radiologists and one chest radiologist independently and retrospectively reviewed the CT scans and classified nodules as benign, malignant, or indeterminate on the basis of nodule size, laterality, number, location, growth, density, margin appearance, and calcification. Generalized estimating equations were used to examine which characteristics were independent predictors of nodule malignancy.

Results

Of the 117 nodules, 80 (68%) were malignant and 37 (32%) were benign by pathologic review. The readers correctly classified 93% to 94% of the malignant nodules. For benign lesions, the results were not as accurate, with the readers correctly classifying only 11% to 30% of lesions. Most of the benign lesions were classified as indeterminate by the readers (54%-65%). Nodule size (≥5 mm) and the presence of calcifications were associated with an increased probability of malignancy (P < .05).

Conclusion

On chest CT, nodule size 5 mm or greater and the presence of calcifications are associated with an increased probability of malignant nodule histology in pediatric patients with osteosarcoma. However, nodule characteristics, apart from size and calcification, at chest CT cannot reliably distinguish benign from malignant pulmonary nodules in these patients.     

A prospective comparative study of the role of CT and MRI-MRCP in the preoperative assessment of obstructive jaundice and their intraoperative corroboration

Background

To compare the diagnostic accuracy of computed tomography (CT) and magnetic resonance imaging-magnetic resonance cholangiopancreatography (MRI-MRCP) in assessing the level and cause of obstruction in patients with obstructive jaundice, and to corroborate the preoperative diagnostic accuracy of MRI-MRCP and CT with operative findings.

Methods

This prospective study included 40 patients with operable obstructive jaundice, whose ages ranged between 20 and 70 years. Diagnosis was based on clinical history, physical examination, biochemical examination, and ultrasonography, followed by CT and MRI-MRCP. The findings of these imaging modalities were compared with intraoperative findings. A statistical analysis was performed to determine the efficacy of CT scanning and MRI-MRCP.

Results

CT is a better modality for diagnosing malignant causes of obstructive jaundice while MRI-MRCP shows excellent results in detecting benign causes.

Conclusion

MRI-MRCP is an excellent modality for the detection of common bile duct stones, but it has its limitations regarding visualization of the periampullary region, whereas CT scanning proved to be useful in delineating the malignant causes of obstruction.