Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

Background: Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies. Methods: The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels. Results: Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence. Conclusions: This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer. Received: 10 May 1996/Accepted: 19 November 1996     

Rocker handle for endoscopic needle drivers

Background: The design of the handle on instruments for endoscopic surgery determines comfort and efficiency of use by the surgeon. This applies particularly to needle drivers. Methods: A novel rocker handle was designed to provide holding comfort and intuitive function. This rocker handle was compared with a finger-loop handle in a study involving 10 surgeons who tied a total of 360 intracorporeal surgeons' knots in a random sequence. The end points in this study were the execution time, knot quality, and motion analysis parameters of the surgeon's elbow and shoulder joints. Results: Intracorporeal surgeon's knots tied with the rocker-handle driver exhibited a better knot quality, although this was not significant (p= 0.097). A significant improvement in the knot quality score (KQS) was observed between the first and the second sessions (p= 0.045) with the rocker handle, whereas no significant learning effect was observed for the finger-loop handle. During intracorporeal knot tying, the angular velocity at the elbow and shoulder joints was consistently lower with the rocker handle, suggesting that more controlled movements are enacted by the surgeon with this handle. Discomfort from finger-loop pressure on the thumb was reported by 3 of 10 surgeons with the finger-loop handle, whereas no discomfort was reported for the rocker handle. Conclusions: The new rocker handle improves the quality of task performance by eliminating discomfort and reducing angular velocities at the shoulder and elbow joints during use. Received: 26 May 1998/Accepted: 12 January 1999     

Laparoscopic four-way ultrasound probe with histologic biopsy facility using a flexible tru-cut needle

Laparoscopic ultrasound (LUS) is widely used in the staging of upper gastrointestinal malignancies. However, accurate N-staging and pathological confirmation of metastases have proved difficult. A new four-way laparoscopic ultrasound probe has been developed. The probe has a biopsy attachment with a needle guide for a flexible tru-cut needle or an aspiration needle. It is now possible to take real-time laparoscopic ultrasound guided biopsies. Furthermore, there is a possibility for interventionel LUS with tumor destruction, celiac plexus neurolysis, and cyst aspiration. In this short technical note, the equipment and the technique are described. Received: 13 April 1999/Accepted: 11 January 2000/Online publication: 20 July 2000     

Thyroid nodules indeterminate by needle biopsy

In our experience with 121 patients 18 (15 percent) thyroid nodules studied by needle biopsy were considered indeterminate relative to the presence of a low-grade, well-differentiated carcinoma. For 11 of, the 18 patients, operation was performed with carcinoma identified in two (18 percent). Although experience reduced this problem, the frequency of carcinoma justifies operation for patients with indeterminate thyroid nodules by needle biopsy, unless other factors dictate otherwise. Inadequate results of fine-needle aspiration biopsy requires a determination of therapy on the basis of other clinical factors. However, permanent disappearance or great reduction in size following aspiration of cystic nodules, repeat biopsy, and biopsy with large needles are important in supporting nonoperative therapy. The indeterminate and inadequate cases must be considered in assessing reports of the use of needle biopsy of thyroid nodules. The large size of a thyroid nodule and previous external radiation therapy are factors supporting operative treatment. Improved selection of patients with benign thyroid nodules for thyroid hormone suppression therapy is needed—thyroid-releasing hormone testing may be of help.     

Tissue diagnosis of new lung nodules in patients with a known malignancy

Background

New lung nodules in patients with known malignancy often represent metastatic disease. However, a lack of pathological confirmation can lead to inappropriate treatment.

Methods

A retrospective review was performed of patients with malignancy undergoing tissue diagnosis of a lung nodule between January 2006 and January 2008.

Results

Ninety-five cancer patients were identified with new lung nodules. Percutaneous biopsy was the first diagnostic procedure in 64 patients, showing metastatic disease in 37 patients and an alternative specific diagnosis in 9 patients. Eighteen biopsies were nondiagnostic. Surgical resection was the first diagnostic procedure in 31 patients. This confirmed cancer in 16 patients and benign disease in 15 patients. Overall, tissue diagnosis changed management in 31% of patients.

Conclusions

Pathological confirmation of metastatic disease is vital before treatment, especially in regions with endemic pulmonary fungal diseases, because a number of lung nodules will represent benign processes despite a history of cancer.     

Minimally invasive surgical biopsy confirms PET findings in esophageal cancer

This report describes our initial experience using positron emission tomography (PET) scanning in esophageal cancer patients. In two patients PET identified distant metastatic disease missed by conventional staging. Laparoscopic biopsy provided histological confirmation of metastases. In the third patient, locoregional lymph nodes were identified by PET and confirmed by surgical staging. In this preliminary report, PET appears to be a promising new noninvasive modality for staging patients with esophageal cancer. Received: 6 December 1997/Accepted: 14 January 1997     

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     

Percutaneous biopsy in evaluation of lung nodules.

Management of an indeterminate pulmonary nodule is a diagnostic challenge that commonly confronts primary care physicians and specialists. Patients often present with this radiographic finding in the course of an unrelated medical evaluation. We examined our institution's experience with percutaneous biopsy of lung nodules to determine the impact of this procedure on overall patient care. Although significant complications are uncommon, the expedience of percutaneous lung biopsy often supplants a surgical opinion prior to initiation of therapy without added diagnostic benefit or cost-savings. Hence, we caution practitioners to use this technique as an adjunct to diagnosis and not a substitute for multidisciplinary care.     

A reliable and efficient technique for laparoscopic needle positioning

Needle positioning can be a difficult, frustrating, and time-consuming step during laparoscopic suturing. Utilizing the reliable and efficient technique described in this article, needle positioning is expedited. This technique is applicable for any type of needledriver or suture. Received: 1 October 1998/Accepted: 7 April 1999     

Minimally invasive surgery and clinical decision-making for pediatric malignancy

Background: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. Methods: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. Results: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. Conclusion: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques. Received: 19 March 1999/Accepted: 27 August 1999     

Operative technique for thoracoscopic transmyocardial laser revascularization

We describe herein the operative steps used to perform a transmyocardial laser revascularization by thoracoscopy. A special technique and specific equipment are required for the efficacy and safety of the procedure. Our preliminary results with this novel approach suggest that it could be a valid alternative to the thoracotomic procedure.     

Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging

Background: The preoperative staging of lung cancer can be problematical when we attempt to evaluate T factor (T2–T3 versus T4) and N factor (N0 versus N1–N2). In some cases, radiology tests (CT scan, magnetic resonance imaging) cannot entirely dispel the possibility that the mediastinal structures have been infiltrated. N factor is evaluated mainly by dimensional criteria. However, mediastinoscopy and mediastinotomy do not allow the full exploration of all mediastinal mode stations. Method: Starting in 1995, we submitted 10 consecutive patients to videothoracoscopic operative staging with ultrasound color Doppler (VOS-USCD). In five cases, preoperative staging showed possible infiltration of the pulmonary artery (T4). In nine cases, we found involvement of the mediastinal nodes, seven patients were N2, and two were N3. Videothoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. The videothoracoscope and sonographic probe were inserted via three thoracoports placed in the axillary triangle. Results: Following the results of VOS-USCD, the staging and subsequently the therapeutic program were modified in seven of 10 cases (70%). Conclusions: Our preliminary experience indicates that VOS-USCD should be applied to the diagnosis of patients in stage IIIA (N2) and that it is particularly valuable for patients in stage IIIB. Received: 23 May 1997/Accepted: 28 October 1997     

Optimal port locations for endoscopic intracorporeal knotting

Port location is crucial for endoscopic manipulations. The aim of the study was to investigate the influence of manipulation, azimuth, and elevation angles of instruments on endoscopic intracorporeal knotting. The standard task was tying a surgeon's knot. Manipulation angles of 30°, 45°, 60°, 75°, and 90° with equal and unequal azimuth angles and elevation angles of 0°, 30°, and 60° were investigated. The endpoints were the execution time and parameters of knot analysis. The execution time was shorter with 60° than with either 90° or 30° manipulation angles (p < 0.0001 and p < 0.01). Equal azimuth angles resulted in a shorter execution time than wide unequal angles (p < 0.001). A combination of 60° manipulation angle with 60° elevation angle had the shortest execution time (p < 0.001) and highest performance quality score (p < 0.02). A range of 45°–75° manipulation angles with equal azimuth angles is recommended. As the manipulation angle increases, the elevation angle has to increase accordingly. Received: 23 July 1996/Accepted: 4 October 1996     

Oxidative stress in lung tissue induced by CO2 pneumoperitoneum in the rat

Background: Clinical trials have found that the pneumoperitoneum has potentially hazardous side effects. The biochemical basis of organ injury induced by pneumoperitoneum is, however, not well defined. Since oxidative stress is believed to play an important role in many pathological conditions, we set out to examine oxidative stress markers in the lung, liver, kidney, and pancreas by using a rat model of laparoscopy with CO₂ pneumoperitoneum and comparing it to a group with gasless laparoscopy. Methods: Malondialdehyde (for lipid peroxidation), protein-bound carbonyls (for protein oxidation), reduced and oxidized glutathione, and the neutrophil marker myeloperoxidase were evaluated in tissue homogenates at 2 h, 6 h, and 18 h after laparoscopy. Immunoblotting was used to analyze the modification of lung proteins by 4-hydroxynonenal at 6 h. Results: Significant lipid peroxidation was found selectively in lungs at 2 h and 6 h after CO₂ pneumoperitoneum. This was accompanied by a loss of glutathione but only minor protein oxidation. Further, lung proteins were clearly modified by the aldehydic product of lipid peroxidation 4-hydroxynonenal. Myeloperoxidase in lungs increased continuously up to 18 h in both experimental groups, but there were higher levels in the group with pneumoperitoneum. Conclusion: Oxidative stress is likely to contribute to the impairment of pulmonary function after laparoscopic operations using a CO₂ pneumoperitoneum. Received: 22 November 1999/Accepted: 22 March 2000/Online publication: 10 July 2000     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000     

Open versus needle biopsy in diagnosing neuroblastoma

Background

Open surgical biopsy is traditionally advocated prior to initiating therapy in UKCCLG neuroblastoma protocols. We report a single centre experience comparing the utility of open biopsy vs image guided needle biopsy in aiding the definitive diagnosis and risk stratification of neuroblastoma – (Shimada classification, MYCN expression, cytogenetics – 1p 11q, 17 q).

Methods

Medical records of all new cases of neuroblastoma presenting to a single UKCCLG centre during January 2002–July 2013 were examined.

Results

Thirty nine patients underwent a biopsy of primary tumour for neuroblastoma during the study. Twenty one children had open biopsy and eighteen cases had a needle biopsy. Staging of neuroblastoma revealed - stage 4 (n = 26), stage 3 (n = 7), stage 2 (n = 3) and stage 4S (n = 3). Sites of primary tumour were adrenal gland (n = 20), abdomen (n = 12), thoracic (n = 4), abdomino-thoracic (n = 2) and abdomino pelvic regions (n = 1). All patients (open vs needle) had adequate tissue retrieved for histological diagnosis of neuroblastoma. One needle and one open biopsy case did not have MYCN status determined despite adequate tissue sampling. Seventeen patients (7 open and 10 needle biopsies) had 1p and 17q status reported in MLPA testing (Multiplex Ligation-dependent Probe Amplification). No single patient required a repeat tumour biopsy. Morbidity in the series was minimal with only one child – open biopsy group, requiring emergent laparotomy to control bleeding from an abdominal primary tumour. No complications were recorded with needle biopsy.

Conclusions

Open and image guided needle biopsy appear to yield adequate tissue sampling for diagnosis, risk classification and staging of neuroblastoma. Further larger co-operative studies may usefully guide national and international protocols.     

Thoracoscopic transdiaphragmatic left adrenalectomy

The endoscopic approach to adrenal glands has been limited to laparoscopic and retroperitoneal access due to the relative inaccessibility of the retroperitoneal space in the former case and to the limited working space in the latter. We undertook this study to investigate the possibility of performing a left adrenalectomy through a thoracoscopic transdiaphragmatic approach in a swine model. Five pigs were anesthetized, intubated, and ventilated. Four laparoscopic trocars were inserted and a left pneumothorax was accomplished by CO₂ insufflation. A peripheral posterior phrenotomy was made starting from the aortic hiatus and extended laterally for about 6 cm. The resulting pneumoretroperitoneum facilitated the subsequent identification of anatomic structures, allowing an easy exposure of the left adrenal gland. The gland was progressively dissected downward, interrupting the tributary vessels with endoscopic clips, and it was finally extracted through one of the trocar ports. Adrenalectomy was accomplished in all the animals without intraoperative mortality. Complications included splenic injury with prolonged bleeding and difficulty in performing the diaphragmatic suture (one case each). Through this approach direct and rapid exposure of the left adrenal gland was allowed, and adrenalectomy was accomplished in all the animals. These results suggest further investigations of the clinical application of this procedure. Received: 6 November 1995/Accepted: 28 May 1996     

Left side thoracoscopically assisted gastroplasty

Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay. Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000