电视胸腔镜下治疗肺叶切除术后支气管胸膜瘘

本文报道 2例肺癌患者行肺叶切除分别于术后第 4、7天出现支气管胸膜瘘。再次手术经VATS直接以无损伤编织线缝合封闭瘘口 ,外用医用合成胶或生物蛋白胶。 2例支气管膜瘘均治愈出院。     

Treatment of pulmonary sequestration by video-assisted thoracic surgery (VATS)

Pulmonary sequestration is a rare malformation of the respiratory tract that accounts for 0.15–6.4% of all congenital lung anomalies. Treatment requires resection of the lesion, provided that there is no technical contraindication. The lession should first be evaluated using video thoracoscopy and then resected whenever possible by video-assisted thoracic surgery (VATS). We report a case of extralobar pulmonary sequestration in a 48-year-old woman. She underwent lobectomy by VATS and achieved an excellent outcome.     

Video-assisted thoracoscopic surgery to the upper thoracic spine

Background: The standard open technique for exposure of the upper thoracic spine, T1–T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically. Methods: A new approach, the so-called ``extended manipulating channel method,' was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients' ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy. Results: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients. Conclusions: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5–3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities. Received: 19 September 1997/Accepted: 3 December 1997     

518例早期肺癌的电视胸腔镜肺叶切除术

目的 探讨采用电视胸腔镜手术(VATS)治疗早期肺癌的理论依据和实践规范,分析影响预后的相关因素.方法 1997年5月至2009年10月,518例早期肺癌患者行VATS肺叶切除术中男297例,女221例;平均年龄(58.9±10.6)岁.结果 术后并发症和手术死亡分别为10.8％和0.4％.患者年龄(P=0.0300,OR=2.0148,95％ CI 1.0700～3.7940)和手术时间(P =0.0007,OR=1.0086,95％ CI 1.0036～1.0136)是影响术后并发症发生率的独立危险因素.1、3、5年总生存率为98％、81％、66％,术后病理分期(P=0.0036,OR=1.6071,95％ CI 1.1677 ～2.2118)是惟一的影响因素.结论VATS肺叶切除术是治疗早期肺癌的一种安全手术方式.对于高龄患者应慎重;手术时间不宜过长;合理处理意外状况、必要时应果断中转开胸有助于降低手术风险.     

Video-assisted thoracic surgery (VATS) of the lung

Background Video-assisted thoracic surgery (VATS) in the diagnosis and treatment of pulmonary diseases has been used since the early 1990s, yet its impact on intraoperative and postoperative morbidity has not yet been fully evaluated. This report aims to provide a retrospective analysis of the literature and the authors’ clinical experience with VATS in pulmonary surgery, with the goal of ascertaining rational criteria that explain operative complications and thus improve outcomes. Methods Over a period of 15 years 1,615 VATS procedures were performed in our department, 743 of which involved only the lung. The accesses employed were based on the use of three ports through which a thoracoscope, endoscopic instruments, and an endostapler were inserted; for major pulmonary resections, a utility thoracotomy without rib spreader was added. Resections less than segmentectomy were performed using the endostapler directly on the parenchyma, whereas in the anatomic resections all the hilar structures were isolated and separately sectioned. Results The procedures performed were as follows: surgical biopsy, 98; wedge resection, 412; segmentectomy, 15; lobectomy, 217; pneumonectomy, 1. Besides the cases in which there were intraoperative complications that could be resolved thoracoscopically, it was necessary to convert to open surgery in 80 patients (10.8%): in 24 (3.3%), for general reasons linked to the technique of VATS itself; in 56 (7.5%), for specific causes correlated to the type of exeresis. The overall postoperative morbidity rate was 8.3% with no deaths. Conclusions The analysis of the literature and our experience show that VATS is a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. To further reduce intraoperative and postoperative morbidity, however, it is necessary to select the patients carefully, to adhere strictly to oncological surgical principles, and to adopt a meticulous technique. Although conversion to open surgery represents failure of VATS, it is mandatory when the procedure is not completely safe.     

Video-assisted thoracic surgery as a primary therapy for primary spontaneous pneumothorax

Background: Because blebs are confirmed in most of the patients undergoing thoracotomy, identification of blebs by high-resolution computed tomography (HRCT) can be proposed as a surgical indication in primary spontaneous pneumothorax (PSP). If an apical bleb is identified, we treat the patient by video-assisted thoracic surgery (VATS). Methods: From May 1995 to September 1997, 61 patients (21.9 ± 4.6 years) were seen for initial episodes of PSP. Only seven showed bullae on simple chest radiography. However, by HRCT, 48 had sizable blebs (>5 mm), and 45 were treated surgically by VATS. Results: The mean duration of chest tube use after surgery was 3.2 ± 1.9 days, and the mean hospital stay was 4.5 ± 1.9 days. Only one recurrence developed 5 weeks after VATS. Conclusions: Our protocol is effective in controlling an initial episode of PSP. It shortens the observation time before definitive surgical treatment, shortens the hospital stay, and decreases the likelihood of recurrence. Received: 25 June 1997/Accepted 18 February 1998     

Video-assisted thoracic surgery (VATS) lobectomy: the evidence base.

BACKGROUND: Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive alternative for management of early stage non-small cell lung cancer, but is still only performed in a few specialized centers around the world. Questions about the safety of the surgery and its adequacy as a cancer operation remain hurdles for many surgeons. METHODS: We performed a systematic review of the literature on VATS lobectomy to assess these questions. The MEDLINE database was queried and the papers analyzed. RESULTS: Four randomized control trials, 11 case-control series, and 10 case series were reviewed. A variety of VATS techniques are used, making generalization of results difficult. The weight of this evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early stage non-small cell lung cancer. There is also evidence that patients experience less pain with VATS, but that length of hospital stay is similar. CONCLUSION: In expert hands, VATS lobectomy appears to be a safe procedure. However, the published evidence is thin and ongoing study is required, preferably with standardization of VATS techniques.     

Fully thoracoscopic pulmonary lobectomy and specimen extraction through rib segment resection

Background: A technique of fully thoracoscopic pulmonary lobectomy with rib-segment resection for specimen extraction is described, and preliminary results in 18 patients are presented. Methods: Surgery is performed through four 15-mm ports. For all lobes except one, the surgeon operates in front of the patient, where the rib spaces are widest and rib-space trauma is less. When lobar dissection is complete, specimen extraction is performed after resection of a rib segment proportional to tumor size. Muscle section is kept to a minimum. There is no rib retraction. Results: There were no deaths, three conversions to open surgery, and three major complications. Average postoperative stay was 5.4 days for patients without complications and 9.6 days for patients with complications. In total six patients presented with some degree of air leaks, and two had post-thoracotomy pain (>2 month's duration). The literature is reviewed to analyze current techniques and to define parameters of a truly minimally invasive pulmonary lobectomy. Conclusions: This technique is safe and promising; however, thoracoscopic lobectomy still needs refining. Before valid randomized studies comparing thoracoscopic lobectomy and muscle-sparing thoracotomy or posterolateral thoracotomy can be credible, technical issues related to the production of a truly minimally invasive procedure should be resolved. Received: 20 August 1996/Accepted: 19 September 1996     

全胸腔镜联合非气腹腹腔镜辅助食管癌根治术与常规手术的对比研究

目的探讨全胸腔镜联合非气腹腹腔镜辅助食管癌根治术较常规开胸手术的优势。方法 2006年11月～2008年5月施行电视胸腔镜联合非气腹腹腔镜辅助食管癌根治术111例(研究组),同期施行常规开胸手术110例(对照组),比较2组患者临床疗效。结果研究组手术时间(272.3±57.9)min显著长于对照组(218.7±91.0)min(t=5.229,P=0.000);研究组术中出血量(219.7±194.4)ml显著少于对照组(590.0±324.4)ml(t=-10.304,P=0.000);研究组术后住院时间(9.6±1.7)d显著短于对照组(11.4±2.3)d(t=6.620,P=0.000)。研究组术后切口液化发生率为0,显著低于对照组6.3%(7/111)(P=0.007)。对照组清扫淋巴结(39.2±12.5)枚,显著少于研究组(44.3±21.0)枚(t=-2.191,P=0.029)。2组病人术后生存率无统计学差异(log-rank检验,χ2=0.348,P=0.555)。结论 全胸腔镜联合非气腹腹腔镜辅助食管癌根治术出血少、恢复快、并发症少、淋巴结清扫更彻底,尽管手术时间较常规手术长,但远期疗效与常规手术相同。     

Video-assisted thoracoscopic surgery (VATS) segmentectomy for small peripheral lung cancer tumors: intermediate results

Background We investigated the feasibility and suitability of video-assisted thoracoscopic surgery (VATS) segmentectomy for curing selected non-small cell lung cancer (NSCLC) with this less invasive technique Methods We performed VATS segmentectomy for small (<20 nm) peripherally located tumors and pathologically confirmed lobar lymph node-negative disease by frozen-section examination during surgery. Of the 34 patients who underwent this limited resection, 22 were treated with complete hilar and mediastinal lymph node dissection (intentional group), whereas 12 patients who were deemed to be high risk in their toleration for lobectomy underwent VATS segmentectomy with incomplete hilar and mediastinal lymph node dissection (compromised group). The surgical and clinical parameters were evaluated and compared with those of segmentectomy under standard thoracotomy to evaluate the technical feasibility of VATS segmentectomy. Results We found that VATS segmentectomy could be performed safely with a nil mortality rate and acceptably low morbidity. The mean period of observation was relatively short at 656.7±572.1 and 783.4±535.8 days in the intentional and compromised groups, respectively. At the time of writing, all intentional patients remain alive and free of recurrence. There were two cases of non-cancer-related death in the compromised group. Clinical data indicated that VATS segmentectomy caused the same number or fewer surgical insults compared with segmen-tectomy under standard thoractomy Conclusions The present results are intermediate only; the rate of long-term survival and the advantages of the less invasive procedure still need further investigation. Nevertheless, we believe that VATS segmentectomy with complete lymph node dissection is a reasonable treatment option for selected patients with small peripheral NSCLC.     

Video-assisted thoracoscopic surgery for right middle lobectomy in children

This case-control study was designed to evaluate the potential advantages and disadvantages of video-assisted thoracoscopic surgery for right middle lobectomy in children. Ten children (6.1±3.0 yr, mean±SD) who underwent right middle lobectomy under videoscopy were compared with 10 controls matched for age (6.8±3.5 yr) and operated by thoracotomy (muscle-sparing technique) during the same period by the same surgeon. Operating time was significantly longer in the videoscopy group than in the thoracotomy group (146±28 mn vs 100±27 mn, P<0.001). Minimum oxygen saturation values were significantly higher in the videoscopy group whereas oxygen requirements did not differ between groups. Incidence of postoperative respiratory complications (mainly atelectasis) was similar in the two groups. No difference in postoperative analgesic requirements in the postoperative period was demonstrated. No real benefit or disadvantage of videoscopy over standard thoracotomy could be observed in this retrospective case-control study.     

Video-assisted thoracic surgery for lung cancer

Objective|The objective of this study was to confirm the safety and feasibility of video-assisted thoracic surgery (VATS) for primary lung cancer and to compare prognoses with that of conventional procedures, and then to examine whether VATS would supplant a conventional thoracotomy for stage I lung cancer. Methods: From September 1995 through March 2002, 144 patients with primary lung cancer, included 118 patients with postoperative state I, underwent VATS lobectomy. We reviewed the previous cases whether they could be candidates for VATS lobectomy according to present indications. 166 cases were supposed to be candidates for VATS, and 121 cases of postoperative stage I disease were recruited into the “conventional thoracotomy” group. Results: There was no mortality or major complication except one case, and mean follow-up was 31.8 months in VATS. The number of removed lymph nodes was not significantly less than the number by conventional thoractomy (p=0.061). Five-year survival for patients with pathological stage IA adenocarcinoma was 92.4% (n=66) in VATS and 86.9% (n=50) in conventional thoracotomy, and a statistical significance could not be recognized (p=0.980). The length of hospital stay was significantly short in VATS lobectomy (p<0.0001). Conclusions: VATS lobectomy for stage I lung cancer can be performed safely with minimal morbidity, satisfying survival comparable with that of lobectomy through conventional thoractomy. VATS approach is a feasible surgical technique for patients with stage I lung cancer.     

Video-assisted thoracic surgery (VATS) for resection of metastatic adenocarcinoma as an acceptable alternative

Background  Adenocarcinomas commonly metastasize to the lungs and can be resected using open thoracotomy or video-assisted thoracic surgery (VATS). This study reviews metastatic resections in primary adenocarcinoma patients, using both thoracotomy and VATS. We aim to compare long-term prognoses to test the efficacy and viability of VATS. Methods  A retrospective review of primary adenocarcinoma patients who underwent resection of pulmonary metastases from 1990 to 2006 was carried out. Information was obtained by chart review. Endpoints analyzed were disease-free interval (DFI), survival time, and recurrence-free survival (RFS). Results  In a total of 42 (16 male, 26 female; median age 58.5 years) primary adenocarcinoma patients, 21 patients underwent first pulmonary metastatic resection using VATS (7 male, 14 female; median age 57 years) and 21 using thoracotomy (9 male, 12 female; median age 59 years). Primary adenocarcinomas were mainly 27 colorectal (64%) and 11 breast (26%). Two VATS (10%) and three open patients (14%) had local recurrences of the original cancer. Median postoperative follow was 13.3 months [interquartile range (IQR) 4.5–32.8 months] for VATS and 36.9 months (IQR 19.3–48.6 months) after thoracotomy. Median DFI–1 was 22.3 months (IQR 13.5–40.6 months) for VATS patients and 35.6 months (IQR 26.7–61.3 months) for open patients. Second thoracic occurrences were noted in six VATS patients (median DFI–2 9.2 months), and in seven open patients (median DFI-2 21.5 months). Third thoracic occurrences were noted in one VATS patient (DFI-3 18.7 months) and in one thoracotomy patient (DFI-3 21.8 months). Odds ratio of recurrence showed 12.5% less chance of developing recurrence in VATS patients. Five-year RFS was 53% in VATS and 57% in thoracotomy patients. Conclusions  VATS has become a viable alternative to open thoracotomy for resection of pulmonary metastases. In cases of primary adenocarcinoma, VATS showed no increase in number of thoracic recurrences, and comparable RFS. Short-term follow-up is encouraging; long-term follow-up will be needed to confirm these results.     

Video-assisted thoracic surgery for thorascopic resection of giant bulla

This report outlines our experience of 6 patients who underwent video-assisted thoracic surgery (VATS) using a linear endoscopic stapler to remove a giant bulla from the lung. Successful treatment with VATS was carried out in 4 patients, but the procedure needed to be changed to a thoracotomy in 2 patients — in one because of difficulty in single-lung ventilation, and in the other, due to a persistent air leak. Thus, we conclude that giant bulla without any associated severe respiratory failure can be an indication for VATS.     

An extrapleural approach to the anterior mediastinum using video-assisted thoracic surgery (VATS)

A lateral extrapleural approach via video-assisted thoracic surgery (VATS) was used in a patient suspected of having a benign tumor of right lobe of the thymus. The patient previously had undergone lung resection for pulmonary tuberculosis, and the ipsilateral thorax had contracted and dense pleural adhesions were likely to exist. Lateral extrapleural approach by VATS was performed successfully and is an alternative to open surgery in highly selected patients with anterior mediastinal lesions.     

Uniportal and three-portal video-assisted thoracic surgery lobectomy: analysis of the Italian video-assisted thoracic surgery group database

Open in a separate window OBJECTIVESThis study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay.METHODSThis was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I–II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy.RESULTSAmong 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P < 0.001). There was a statistical difference on the second and third postoperative days; odds ratio (OR) 2.28 [95% confidence interval (CI) 1.62–3.21; P < 0.001] and OR 2.58 (95% CI 1.74–3.83; P < 0.001), respectively. The uniportal-VATS group had higher operative time (P < 0.001), shorter chest drain permanence (P < 0.001) and shorter length of stay (P < 0.001).CONCLUSIONSData from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.     

Video-assisted anatomic mediobasal segmentectomy of lung

Although video-assisted thoracic surgery (VATS) is now widely accepted, pulmonary segmentectomy is rarely performed. We present a case series of patients undergoing this procedure. The first patient had multiple arteriovenous malformations of the right mediobasal segment and a leiomyoma in the bronchus of the mediobasal segment. The second patient had multiple pulmonary metastases from colon cancer, including one in the right mediobasal segment. The third patient had metastases in the right ventrobasal and mediobasal segments from a solitary fibrous tumor that originated in the contralateral diaphragm. In the first two patients, a solitary mediobasal segmentectomy was done. In the third patient, a combined ventrobasal and mediobasal bisegmentectomy was performed. There were no complications, and visualization was excellent. Because VATS provides such excellent exposure, mediobasal segmentectomy of the lung is feasible, even though this operation is not done as an open procedure.     

54例胸外伤辅助小切口电视胸腔镜手术报告

目的　通过辅助小切口配合电视辅助腔镜手术 (VidoAssistedThoracospicSurgery ,VATS) ,扩大VATS手术适应范围。　方法　对 5 4例胸外伤患者使用VATS辅以小切口进行肺叶切除术、肺楔形切除术、肺破裂修补术、膈肌破裂修补术。　结果　 5 4例治愈出院。术后恢复快 ,住院天数 8天～ 12天 ,平均 10天。切口甲级愈合 ,术后无并发症。　结论　辅助小切口配合VATS能完成与常规开胸术同等质量的胸部手术 ,使诊治同步进行 ,扩展了VATS的手术适应范围。     

Video-assisted thoracoscopic repair of an intercostal pulmonary hernia

Pulmonary hernias are extremely rare. They are usually treated with open surgical procedures. We describe a case in which a large, spontaneously acquired intercostal pulmonary hernia was successfully repaired by video-assisted thoracoscopic surgery (VATS). Received: 12 August 1996/Accepted: 26 November 1996     

Video-assisted thoracoscopic surgery in the management of loculated empyema

Background: Fibropurulent empyema (stage II of Light) does not respond to antibiotic therapy and simple drainage. If the condition is inadequately treated, restrictive pulmonary deficit develops, necessitating thoracotomy and decortication. We report our experience with the videoscopic management of stage II and limited stage III disease. Methods: Ten consecutive patients underwent videoscopic debridement of fibropurulent empyema; three of them required removal of limited visceral and parietal rind. Results: The mean operating time was 42 ± 8.1 min. Postoperative pyrexia and leucocytosis settled within 4.2 ± 2.1 days and 13.1 ± 3.2 days, respectively. Intercostal chest tubes were removed by 4.5 ± 1.0 days. The mean fall in hematocrit following surgery was 4.9%. Parenteral analgesics were required for 1.0 ± 0.5 days and oral analgesics for 3 ± 1.6 days. The mean postoperative stay was 11 ± 8.1 days. No patient required any further intervention. Conclusions: Videoscopic debridement of empyema produces excellent results, with minimal patient morbidity and a short hospital stay. We recommend it as the preferred method for first-line management of fibropurulent (stage II) empyema. Received: 10 December 1998/Accepted: 13 May 1999