Treatment of mediastinitis using video-assisted thoracoscopic surgery

Background: Mediastinitis remains a life-threatening disease that is difficult to manage and has a poor prognosis. This is especially true of descending necrotizing mediastinitis, which before the 1990s era had a mortality of approximately 40% despite the use of antibiotics, surgical techniques, and intensive care monitoring. Several authors have recommended that aggressive surgical approaches for mediastinitis are more effective than simple surgical approaches; however the best surgical option for mediastinitis remains controversial. Materials and methods: In a retrospective analysis between January 2000 and June 2006, 17 patients who underwent surgical debridement and drainage using video-assisted thoracoscopic surgery are included in this report. Data extracted from medical records included sex, age, origin of infection, surgical intervention, progress, and outcome including cause of death. There were eight men and nine women. The mean age was 52 years old (range, 20-72). Results: The origins of infection included esophageal perforation in nine patients and odontogenic or peritonsillar abscesses in the remaining eight patients. Among them, two patients required conversion to thoracotomy during operation in cases of mediastinitis due to esophageal perforation, so excluding the two patients, we calculated next five data for 15 patients. The mean duration from onset of symptoms to surgery was 12.4+/-13.1 days (range, 0-43) and the mean duration from the initial operation to discharge was 43.6+/-24.4 days (range, 8-113). There was serial operation in one case. There were three cases of postoperative mortality. Conclusion: Mediastinal drainage using video-assisted thoracoscopic surgery with or without cervical drainage can be a feasible and effective surgical option. This less invasive technique seems to have an outcome similar to more aggressive open surgical approaches for patients with mediastinitis previously reported in the literature, although it has not been directly compared.     

Resection of a thoracic duct lymphangioma using video-assisted thoracoscopic surgery

Thoracic duct lymphangioma is a rare mediastinal tumor. Most patients are asymptomatic. Symptoms may include dysphagia, dyspnea, cough, or chest pain. Workup may include chest computed tomography or lymphangiography, or both. Surgery should be considered the treatment of choice. We present a 60-year-old man with a 2.4-cm mass in the retro-cardiac space to the right of the esophagus. The patient underwent a thoracoscopic resection of the mass with ligation of the thoracic duct. We conclude that video-assisted thoracoscopic surgery allows for safe evaluation and resection of mediastinal pathology.     

微创外科与电视胸腔镜

外科是采用手术治疗疾病的学科。手术治疗疾病必然会产生创伤,尤其传统胸外科手术切口长、创伤大,给患者生理和心理带来较大的影响。长期以来,以较小的创伤达到较好的治疗效果一直是外科医生追求的目标。近年来随着高科技在医学领域的应用,以腔镜为代表的微创外科手术深受广大患者的欢迎,微创外科技术正在被愈来愈多的胸外科医生所接受,并得到推广和应用。[第一段]     

Treatment for pinch-off syndrome using a video-assisted thoracoscopic surgery; report of a case

Use of a central venous catheter (CVC) may be complicated by a catheter fracture, causing an embolism. Pinch-off syndrome is a recognized complication that develops from the use of implantable subclavian venous access devices. Although rare, as it occurs in only 0.8% of the reported cases, the condition can appear as a complication secondary to the insertion of a CVC. We experienced a case of CVC division in a 26-year-old male who had a CVC implanted through the subclavian vein. We failed in our attempt to remove the catheter fragment using video-assisted thoracoscopic surgery (VATS). If no complication occur over a long-term, it is highly possible that the catheter fragment will become adhered to the vessel wall. Therefore, it may not be necessary to remove the fragment in those cases.     

Complications of video-assisted thoracoscopic surgery

We introduced video-assisted thoracoscopic surgery (VATS) for chest disorders in our institution in March, 1992. At first, many of the subjects' disorders were non-malignant diseases such as spontaneous pneumothorax, but later we started to perform this procedure for lung cancer and mediastinum neoplasm, with improved result over thoracoscopic surgical procedures. Now most of the chest disorders at our institution are treated with VATS. However, many kinds of complications due to manual techniques and instrument troubles surfaced during this period. Therefore, in this article we would like to describe the complications that we have experienced in our institution using VATS and discuss how we have attempted to deal with these complications.     

Results of video-assisted thoracoscopic surgery for pneumothorax

INTRODUCTION: Video-assisted thoracoscopic surgery has been used in the treatment of pneumothorax since 1990. There is still no general agreement regarding the procedure to obliterate the pleural space or regarding the indication for wedge resection if no blebs or bullae can be found. PATIENTS AND METHODS: Clinical records referring to 100 video- assisted thoracoscopic operations for pneumothorax, performed in Berlin-Buch between 1998 and 2001, were retrospectively evaluated with regard to the rate of recurrences and postoperative complications in connection with the operative procedure. There were 70 male and 28 female patients aged from 16 to 78 years. The mean age was 34 years. The statistical significance was evaluated by the McNemar-test. RESULTS: 74 patients showed a regular postoperative course. Severe postoperative complications occurred in 9 patients: re-operation via thoracotomy n=5 (postoperative bleeding n=2, recurrence n=2, persistent air-leak n =1); re-thoracoscopy n=3 (postoperative bleeding n=2, recurrence n=1), pleural empyema n=2. The complication rate was significantly higher (p < 0.001) in patients with underlying pulmonary diseases (secondary spontaneous pneumothorax) or thoracic surgery in their history. Depending on the intraoperative situation, the cause of pneumothorax and the patient's general condition the pleural space was obliterated by the following procedures: apical parietal pleurectomy (n=85), electro-pleurodesis alone (n= 7), electro-pleurodesis and pleural abrasion (n=3), talcum poudrage (n=2). The rate of major complications was lower (p < 0.001) when pleurectomy was performed 8.2 % (7/85) compared to those operations performed without pleurectomy 13.3 % (2/15). The rate of re-operations for recurrences/persistent air leaks or empyemas following persistent air leaks was significantly lower (p < 0.001) when wedge resection 3.75 % (3/80) had been performed compared with operations without wedge resection 10 % (2/20). DISCUSSION: Apical parietal pleurectomy and wedge resection of blebs or bullae are effective methods to prevent recurrences. Considering the specific complications of parietal pleurectomy alternative methods to obliterate the pleural space should be used depending on the intraoperative situation. Among other factors underlying pulmonary diseases or thoracic surgery in the patient's history strongly influence the postoperative outcome independently of the operative procedure.     

Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery

BACKGROUND: Descending necrotizing mediastinitis is a rare but serious disease. Aggressive surgical approaches have been emphasized rather than simple medical treatment. METHODS: Four patients with descending necrotizing mediastinitis were treated surgically in our institution between January 2001 and August 2002. Three had peritonsilar abscesses and one had an odontogenic abscess. Operative procedures included drainage and debridement through a Chamberlain incision and neck incision using video-assisted thoracic surgery. RESULTS: The mean duration from symptoms to operation was 5.3 days (range, 3 to 7) and mean hospital stay was 28.8 days (range, 14 to 47). There was no perioperative mortality. Postoperative complications were found in three patents: two with localized pleural effusion and one with a hydropneumothorax. CONCLUSIONS: Video-assisted thoracic surgery is feasible and effective as a less invasive method for the surgical management of patients with descending necrotizing mediastinitis, especially when applied early.     

Emergency video-assisted thoracoscopic surgery for intrathoracic foreign bodies

The aim of this retrospective study is to highlight the advantages of video-assisted thoracic surgery (VATS) in the assessment of thoracic trauma. In the past 4 years 3 patients had intrapleural or intrapulmonary Kirschner needles which penetrated from the site of a previous humeroscapular osteosynthesis and one patient with a gunshot projectile and haemothorax in the left thorax. They were treated by VATS removal of intrathoracic foreign bodies. No complications developed postoperatively, the chest wall pain was minimal, the duration of hospital stay (3-5 days) and recovery was short. The widespread use of minimal invasive VATS procedure is an alternative approach that provides safe and less invasive operation for acute chest trauma patients. We believe that its extended use for both diagnostic and therapeutic purposes even in some special circumstances is justified today.     

电视胸腔镜手术在肺癌治疗中的应用

电视胸腔镜手术（video-assisted thoracoscopic surgery，VATS）是一种微创、安全、可行的技术。随着手术器械和技巧的日趋改进，电视胸腔镜在临床的应用越来越广泛。本文就电视胸腔镜手术在肺癌治疗中的应用作一综述。     

电视胸腔镜手术在胸外科的应用

目的探讨电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)在胸外科的应用. 方法回顾分析1998年7月～2002年12月78例胸腔镜手术的临床资料.其中:自发性气胸肺大疱切除40例,胸外伤探查12例,肺包块楔形切除9例,胸膜活检 胸膜固定6例,纵隔肿瘤切除4例,肺叶切除4例,肺叶切除术后支气管胸膜瘘2例,食管平滑肌瘤切除1例. 结果无一例中转开胸,5例因胸膜顶粘连辅助小切口.3例中老年自发性气胸术后持续漏气,分别于第7,8,13天拔除胸管,其余均在48h内拔除胸管.5例引流管口延期愈合.手术并发症发生率10.3%(8/78). 结论 VATS在胸外科有广阔的发展空间,一次性耗材价格昂贵限制其临床应用,腔镜下缝合技术或打结技术的应用比较适合目前的国情,节省医疗费用.     

Port-site recurrence following video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery (VATS) is an established modality in the management of pleural diseases. We report a case of port-site recurrence following management of malignant pleural effusion in an elderly patient with extensive pleural metastasis from adenocarcinoma of the lung. Although her shortness of breath was relieved following VAT decortication and talc insufflation, at 3 months she was found to have a 2.5-cm subcutaneous nodule at the camera port site which on biopsy was confirmed to be metastatic in nature. Even though the nodule was asymptomatic and the patient prognosis was not affected, it is important that both the surgeon and future patients should be aware of this potential complication.     

Lobectomy under video-assisted thoracoscopic surgery for pulmonary aspergillosis

A 70-year-old man was admitted to our hospital because of hemoptysis and abnormal shadows on chest film. He was given a diagnosis of pulmonary aspergilloma with fungus ball by computed tomography and other evaluations. Success rate of systemic or topical treatment with antifungal agents is reported to be 80%. At this case lobectomy under VATS was chosen because he had chronic liver dysfunction by hepatitis type C and the lesion was localized in the right upper lobe. Bronchial artery embolization was performed prior to the operation in order to minimise bleeding on lysing the adhesion between the chest wall and the lobe with aspergilloma. Operation was underwent safety with a bloodloss of 170 ml. Success rate of operation is reported to be 95.8% in pulmonary resection. If bronchial artery embolization is successful and the lesion is localized, lobectomy under VATS can be good option in selected patients.     

经胸腔镜冠状动脉旁路移植术的麻醉

目的探讨经胸腔镜冠状动脉旁路移植术(VATCABS)麻醉方法.方法回顾性分析14例VATCABS麻醉方法,总结术中重要处理及麻醉相关并发症.结果患者芬太尼药量为13.3±7.3μg/kg.14例中6例(42.9%)在手术内拔除气管内插管.8例带管回ICU,术后(4.71±2.21)小时拔除气管插管,ICU留住时间为(45.2±35.5)小时.平均手术时间为(4.24±1.8)小时.围术期无麻醉相关的并发症.结论"快车道”麻醉方案适用于VATCABS麻醉.     

Cost-containing strategies in video-assisted thoracoscopic surgery

Background: Video-assisted thoracoscopic surgery (VATS) is now an established approach in the management of many thoracic conditions. However, the high cost of this new technology has deterred many Asian hospitals from widely applying this technique. Methods: This article describes our strategies to reduce cost in our practice of VATS over the last few years. Results: VATS involves (1) careful patient selection, (2) use of conventional thoracic instruments as much as possible, (3) modification of conventional instruments, (4) limited use of expensive consumables, and (5) development and application of endoscopic suturing technique. Conclusions: VATS is still in evolution. Cost containment, while desirable in the West, is a high priority in Asia if this new surgical approach is to be applicable even in developing countries. More research is greatly needed in this area. Received: 13 February 1996/Accepted: 10 June 1996