Is video-assisted thoracic surgery justified at first spontaneous pneumothorax?

OBJECTIVE: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. CONCLUSIONS: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.     

The utility of BiClamp? for intraoperative air leakage control in video-assisted thoracic surgery for pulmonary lobectomy

We describe a simple technique of controlling air leakage from the lung parenchyma using BiClamp^?. The device creates appropriate protein coagulation at an air leakage point of the lung parenchyma. The leakage point and adjacent area are grasped with BiClamp^? forceps and coagulated without tissue carbonization. After the procedure, no air leakage was recognized under airway pressure test of 15?C20 cmH₂O. This method is easy to handle, especially in video-assisted thoracic surgery lobectomy with an economical advantage as ??Ecosurgery??.     

Is video-assisted thoracic surgery indicated in the first episode primary spontaneous pneumothorax?

Primary spontaneous pneumothorax (PSP) is a very common disease and recurrence is a major concern for the post-first-time victims. Owing to the convenience and popularity of video-assisted thoracoscopic surgery (VATS), should we still wait for recurrence before we perform this minimal invasive procedure to cure the disease? Between 1997 and 2002, 51 patients of PSP from the first episode received VATS the day after their admission at Kaohsiung Medical University Hospital. Forty-five patients (90%) were found to have blebs (mostly above the upper lobe). They all received wedge resection plus pleural abrasion. No mortality was recorded. The average postoperative hospital stay was 4 days. After a follow-up period of 38 months, no recurrence or complication was found. The patients are now living in good health. We found a high percentage of blebs. These are possible causes of subsequent recurrence. Surgical intervention with VATS for the first episode of PSP is safe, effective, and cosmetically excellent. The most important thing is that the fear of recurrence is finally resolved.     

Not palpable? Role of radio-guided video-assisted thoracic surgery for nonpalpable solitary pulmonary nodules

Purpose  

This study aimed to evaluate the effectiveness of radio-guided localization for thoracoscopic resection of small nonpalpable lung nodules.     

Is incentive spirometry effective following thoracic surgery?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether incentive spirometry is a useful intervention for patients after thoracic surgery. Altogether 255 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that incentive spirometry is a relatively good measure of lung function and may be used to assess respiratory recovery in the days after thoracic surgery. Physiotherapy either with or without incentive spirometry reduces the incidence of postoperative complications and improves lung function but there is currently no evidence that incentive spirometry in itself could either replace or significantly augment the work of the physiotherapists. Clinicians should be aware that while incentive spirometry can provide an assessment of lung recovery, well-organised and regular physiotherapy remains the most effective mechanism to augment their patient's recovery and avoid postoperative complications.     

Is pneumonectomy using video-assisted thoracic surgery the way to go? Study of data from the Japanese Association for Thoracic Surgery

Background

The number of pneumonectomies performed has been decreasing every year. That decrease is the result of changes in distribution of histological type, stage, and tumor location. To investigate the results of pneumonectomies performed on lung cancer patients in Japan over a period of 15 years, data reported by the Japanese Association for Thoracic Surgery were analyzed.

Methods

All data shown in the table were derived from official records reported in Japan. Mortality refers to hospital death rather than 30-day death, to more precisely evaluate the safety of the operations.

Results

(1) The number of sleeve lobectomies did not increase. (2) The operative mortality rate with pneumonectomies did not fall. In 2011, the rate of hospital deaths among pneumonectomy patients rose to 3.9 % and worsened to 5.3 % in 2012, which was more than twice that of 30-day death, despite an improvement in results as a whole. (3) The incidence of lethal bronchopleural fistula showed very little improvement, declining from 11.7 to 9.6 %. (4) In 2012, VATS was used in 13.1 % of all pneumonectomy patients. That figure stood at only 0.5 % in 1997.

Conclusion

Regarding pneumonectomies performed in Japan during the period analyzed, use of the less-invasive approach increased but bronchopleural fistula was still a major complication. The rate of hospital deaths among pneumonectomy patients worsened 2 years in a row. What is of critical importance is not the choice of approach—VATS or open thoracotomy—but the surgeon’s efforts to find a chance to perform lung-saving surgery.     

Quality of life one year after myocardial revascularization. Is preoperative quality of life important?

Of 428 patients, mean age of 64.1+/-9.2 (30-84 years), undergoing an isolated CABG, pre- and one-year- postoperatively angina level and quality of life (QOL) were registered. QOL was registered following the EuroQol-registration, five domains and a visual analogue scale (VAS). Based on the VAS, the group was divided into Group A, 168 patients with a VAS < 60 and Group B, 260 patients with a VAS > or = 60. One-year postoperatively, 394 patients (92.%) indicated to be angina-free. The VAS of the total group was significantly higher one-year post-CABG, 75.3 vs. 61.7 (P=0.00). Of group A, 88% of patients registered a higher VAS. In group B only 60.8% registered a higher and 26.9% a lower VAS. Multivariate analysis identified preoperative VAS < 60 and a preoperative mobility level > 1 as independent predictors for an increased QOL. Thus our conclusion is that relief of angina one year post-CABG is associated with an increased QOL, however, patients with a relatively poor preoperative QOL have a more beneficial QOL. But patients with a good preoperative QOL can lose a lot of QOL.     

Cardiac surgery in octogenarians: can elderly patients benefit? Quality of life after cardiac surgery

Background. Increasing numbers of the very old are presenting for cardiac surgical procedures. There is little information about quality of life after hospital discharge in this group.

Methods. From March 1995 to February 1997, 127 patients older than 80 years at operation (mean age, 83 ± 2.5 years; range, 80 to 92 years) were entered into the cardiac surgery database and analyzed retrospectively. The RAND SF-36 Health Survey and the Seattle Angina Questionnaire were used to assess quality of life by telephone interview (mean follow-up, 15.7 ± 6.9 months). No patient was lost to follow-up.

Results. Operations included coronary artery bypass grafting (65.4%), coronary artery bypass grafting plus valve replacement (15.8%), and isolated valve replacement (14.2%). Preoperatively, 63.8% were in New York Heart Association class IV. Thirty-day mortality was 7.9%, and actuarial survival was 83% (70% confidence interval, 79% to 87%) at 1 year and 80% (70% confidence interval, 75% to 85%) at 2 years. Preoperative renal failure significantly increased the risk of early death (relative risk, 3.96) as did urgent or emergent operation (relative risk, 6.70). In addition, cerebrovascular disease (relative risk, 3.54) and prolonged ventilation (relative risk, 3.82) were risk factors for late death. Ninety-five patients (92.2%) were in New York Heart Association class I or II at follow-up. Seattle Angina Questionnaire scores for anginal frequency (92.3 ± 18.9), stability (94.4 ± 16.5), and exertional capacity (86.8 ± 25.1) indicated good relief of symptoms. SF-36 scores were equal to or better than those for the general population of age greater than 65 years. Of the survivors, 83.7% were living in their own home, 74.8% rated their health as good or excellent, and 82.5% would undergo operation again in retrospect.

Conclusion. Octogenarians can undergo cardiac surgical procedures at a reasonable risk and show remarkable improvement in their symptoms. Elderly patients benefit from improved functional status and quality of life.     

Quality of life in rectal cancer surgery:What do the patient ask?

Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision (TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques (pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.     

Is video-assisted thoracoscopic surgery the best treatment for paediatric pleural empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracic surgery (VATS) is the best treatment for paediatric pleural empyema. Altogether 274 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that early VATS (or thoracotomy if VATS not possible) leads to shorter hospitalisation. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs. 3.3%), re-intervention rate (2.5% vs. 23.5%), length of stay (10.8 days vs. 20.0 days), duration of tube thoracostomy (4.4 days vs. 10.6 days), and duration of antibiotic therapy (12.8 days vs. 21.3 days), compared with patients who underwent non-operative therapy. Similar complication rates were observed for the two groups (5% vs. 5.6%). Moreover, median hospital charges for VATS were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiological imaging charges were $5884 (IQR, $3142-$11,357) and $2875 (IQR, $1703-$4950), respectively, for VATS and tube drainage. Adjusting for propensity score matching, costs for primary VATS were equivalent to primary chest tube placement. Only one article found discordant results. Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and eight chest tube followed by VATS/thoracotomy); only four received fibrinolytics. Mean (standard deviation) length of stay was significantly shorter in the antibiotics alone group, 7.0 (3.5) days vs. 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>1/2 thorax filled).