胸腔镜手术的临床应用

作者等自１９９２年１１月至１９９４年３月，用胸腔镜进行胸部手术３６例次，其中包括反复发作的自发性气胸、肺大跑切除、胸膜固定术１４例（双侧病变同时手术１例）；肺周围型肿物，肺楔形切除术１０例；恶性胸水、胸膜活检、胸膜固定术４例；胸膜病变，胸膜活检术３例；肺部肿瘤活检术２例；双肺弥漫性病变，肺活检术２例；中转开胸２例。无手术死亡和严重并发症发生。取得较为满意的诊断和治疗效果。与同期开胸探查手术相比较，胸腔镜手术创伤小，术后疼痛轻，胸腔引流量、置管时间、术后住院日都有不同程度的减少或缩短。     

胸腔镜手术临床应用

作者等自１９９１年１１月至１９９４年３月，用胸腔镜进行胸部手术３６例次，其中包括反复发作的自发性气胸、肺大切除、胸膜固定术１４例（双侧病变同时手术１例）；肺周围型肿物，肺楔形切除术１０例；恶性胸水、胸膜活检、胸膜固定术４例；胸膜病变，胸膜活检术３例；肺部肿瘤活检术２例；双肺弥漫性病变，肺检术２例；中转开胸２例。无手术死亡和严重并发症发生。取得较为满意的诊断和治疗效果。与同期开胸探查手术相比较，胸腔     

胸腔镜胸膜固定术的临床应用

目的 探讨胸腔镜胸膜固定术治疗气胸和恶性胸积液的效果。方法 对1997年9月至2003年9月间采用胸腔镜胸膜固定术治疗气胸和恶性胸积液患者30例进行回顾性分析，其中肺大泡合并自发性气胸21例，恶性胸腔积液9例。结果 本组所有患者无手术死亡。21例肺大泡患者经胸腔镜切除肺大泡并胸膜固定手术，术后平均住院时间7．4天，引流管放置时间2．8天，胸腔引流量180ml，无气胸复发。9例恶性胸腔积液患者术后平均住院时间11．2天，引流管放置时间4．4天，平均胸腔引流量420ml，随访3～16个月未见胸积液复发。结论 使用胸腔镜施行胸膜固定术具有疗效确切、创伤小的优点，可以有效地防止气胸和胸积液复发。     

电视胸腔镜手术诊治255例不明原因胸腔积液

目的 探讨电视辅助胸腔镜手术（video assisted thoracoscopic surgery,VATS）对胸腔积液的诊治价值。方法 回顾分析1995年3月～2005年12月255例不明原因胸腔积液经电视胸腔镜手术的临床资料。均经双腔气管插管静吸复合全麻,健肺单肺通气。对包裹形成者先做包裹分离,然后吸尽胸腔积液,再探查有无胸膜结节及肺部结节或肿块,对可疑病灶多点取材做冰冻切片活检。肺复张不完全者,进行纤维板剥脱术。根据病理结果采取胸腔冲洗、胸膜固定及胸腔内化疗等处理方法。结果 255例均经术中冰冻病理检查确诊,其中57例恶性,153例结核性,45例炎性。全组无术中并发症。手术时间60～140min,平均97min。出血量100～850ml,平均226ml。术后222例肺膨胀完全,33例因肿瘤压迫肺膨胀不完全。恶性胸腔积液患者术后随访存活者14例,存活时间12～20个月,平均16.8个月,其余43例在6～12个月内死亡。结核性胸腔积液者142例随访2年,2例在术后1年左右复发,经胸穿治疗好转。炎性胸腔积液41例随访1年无复发。结论 电视胸腔镜在胸腔积液的处理中具有快速、安全、微创、准确诊断等优点,是有效的治疗手段。     

局麻下纤维支气管镜代胸腔镜在恶性胸腔积液诊治中的应用

目的探讨纤维支气管镜代胸腔镜在恶性胸腔积液的诊断和治疗中的作用。方法 2002～2010年,对26例恶性胸腔积液在血氧监护、局部麻醉下置入纤维支气管镜探查胸膜腔,并以活检钳行病变活检,肿瘤减灭,滑石粉胸膜固定。结果病理确诊率84.6%（22/26）,诊断恶性22例,1例因胸膜坚韧无法活检,3例胸膜活检未见肿瘤细胞。胸水控制完全缓解（CR）16例,部分缓解（PR）9例（肺不能完全复张）,疾病进展（PD）1例（肺不能复张）。CR＋PR共25例,有效率96.2%。结论纤维支气管镜代胸腔镜行胸膜活检及胸膜腔滑石粉固定,手术风险小,诊断率及治疗有效率高,在恶性胸腔积液的诊断和治疗中具有很高的临床价值。     

胸腔镜在恶性胸腔积液治疗中的应用价值

目的探讨电视胸腔镜在胸腔积液病因诊断及治疗中的价值。方法 2009年7月~2015年11月对27例疑似恶性胸腔积液,经胸腔镜探查行肿物活检及胸膜固定术。结果 27例均确诊,其中原发肺癌18例,肺外转移癌9例。均未出现严重并发症。术后第4周胸部X线片示CR 16例(肺癌胸膜转移13例,转移癌3例),PR 9例(肺癌胸膜转移3例,转移癌6例),SD 2例(均为肺癌胸膜转移),有效率92.6%(25/27)。结论电视胸腔镜在胸腔积液病因诊断及治疗中具有较高价值。     

电视纵隔镜在恶性胸腔积液诊治中的应用

目的探讨电视纵隔镜在诊治恶性胸腔积液中的应用价值。方法回顾分析自2003年10月至2004年4月12例恶性胸腔积液患者行电视纵隔镜胸膜活检+滑石粉胸膜固定术治疗的临床资料。结果术后病理诊断腺癌8例,鳞癌4例;肺癌胸膜转移11例,食管癌肺、胸膜转移1例;手术诊断率100%,有效率91.7%(11/12),全组无手术死亡。术后发生低热3例,经处理后退热;胸痛3例,经止痛后缓解。结论电视纵隔镜对恶性胸腔积液的诊断和治疗有良好的临床效果。     

内科胸腔镜检查在恶性胸腔积液诊断中的应用价值

目的评价内科胸腔镜检查在恶性胸腔积液诊断中的应用价值。方法回顾性总结经胸腔积液细胞学、痰细胞学、气管镜、闭式胸膜活检等仍不能确诊胸腔积液性质,临床上高度疑诊恶性胸腔积液者,采用内科胸腔镜下病理组织活检诊断为恶性胸腔积液的81例患者的临床资料。结果肺癌53例,其中肺鳞癌7例,肺腺癌30例,肺腺鳞癌6例,小细胞癌10例;胸膜转移癌18例,其中乳腺癌转移6例,卵巢癌转移3例,肾透明细胞癌并胸膜转移3例,恶性胸腺瘤转移2例,其他部位癌转移4例;恶性胸膜间皮瘤7例;非霍奇金淋巴瘤3例。结论对有肿瘤病史、大量胸腔积液者、胸部CT提示肿块影或胸膜病变常规方法检查不能明确病因而临床上高度怀疑为恶性胸腔积液,早期积极进行内科胸腔镜检查是一种安全、易行、准确的诊断方法。     

电视胸腔镜手术诊治恶性胸腔积液

目的:探讨电视胸腔镜手术(VATS)诊治恶性胸腔积液的安全性和效果。方法:自2001年6月至2002年6月对7例胸腔病人实施了VATS诊治。均行胸腔活检、滑石粉喷洒胸腔固定术。结果:6例获得明确的病理诊断,4例为癌胸膜转移,2例为恶性间皮细胞瘤。1例未明确诊断,无术后严重并发症和死亡。随访1～8个月,胸腔积液均得到控制,未见复发。结论:电视胸腔镜手术在诊治恶性胸水方面有明显的优点。     

电视胸腔镜对恶性胸水治疗探讨

目的:探讨电视胸腔镜对恶性胸水的手术治疗效果。方法:回顾性分析33例恶性胸腔积液电视胸腔镜手术治疗效果。本组病例33例,30例术前有不同程度的胸闷气喘。病史5周～10个月,单侧胸水28例,双侧胸水5例,大量胸水者11例,中等量胸水者19例,少量胸水者3例,全组病例术前均行胸穿抽液,平均抽液量1500ml,血性胸水30例,草黄色胸水3例。11例术前曾行针刺胸膜活检术,可疑癌性胸水3例。结果:33例患者,14例术前已明确原发癌灶,余19例术中均经病理检查确诊为恶性胸腔积液,其中肺腺癌18例,肺鳞癌9例,肺未分化癌1例,乳腺癌肺转移2例,转移性卵巢癌3例。全组病例均行喷洒滑石粉胸膜固定术,获得永久的完全胸膜固定,术后第2天胸引量明显减少,术后置胸引管约3～8天,平均4天,术后平均引量270ml。胸透证实肺复张后拔胸引管。结论:电视胸腔镜对恶性胸水是一种重要的定性检查和治疗手段,值得临床上广泛应用。     

Long-term follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions.

OBJECTIVE: Recurrent pleural effusion is a common condition and often presents a challenge for treatment. The aim of this report is to evaluate the long-term follow-up of thoracoscopic management of malignant recurrent pleural effusions. METHODS: From July 1st, 1992 to February 28th, 2001, out of 2311 VATS procedures performed at our Institution, 690 patients (29.85%) underwent videothoracoscopy (VATS) for recurrent pleural effusion. Of these 611 (88.55%) were treated for a malignant pleural effusion. There were 374 male and 237 female, with a mean age of 61.2 years. In all patients VATS was performed under general anaesthesia. The pleural effusion was carefully aspirated; fibrinous adhesions were taken down while dense fibrous adhesions were selectively divided; some limited decortications were also performed. Multiple pleural biopsies were always performed. Pleurodesis was performed with 5 g of sterile purified talc insufflated through a talc atomizer. One chest tube was left in situ for 3-5 days. RESULTS: Operative mortality was 0.81% (five cases). Postoperative complications occurred in 19 cases (3.1%). Specific histologic diagnosis was obtained in all patients. Follow-up was available for 602 patients (98.5%). After a median follow-up of 64 months (range 5-105 months), talc pleurodesis was successful in controlling recurrence of effusion in 92.7% (558 out of 602) of patients. The success rate did not show any statistically significant difference between patients who underwent postoperative adjuvant therapy and patients who did not. In two patients with failure of talc pleurodesis a redo-VATS was performed. CONCLUSIONS: VATS represents the method of choice for both diagnosis and treatment of malignant recurrent pleural effusions. Talc poudrage is safe and effective in obtaining pleurodesis.     

Palliative treatment of malignant pleural effusions by video-assisted thoracoscopic surgery

Malignant pleural effusion (MPE) are associated with significant morbidity. Prompt clinical evaluation followed by aggressive treatment often results in successful palliation. Video-assisted Thoracic Surgery (VATS) today can be employed in the diagnosis and treatment of idiopatic and known MPE. Between January 1994 and December 1998 233 MPE patients were treated with pleurodesis. 206 of them underwent tube thoracostomy and drainage alone followed by chemical pleurodesis. In 27 out of the 233 cases VATS management was applied. These patients had undiagnosed pleural effusions or recurrent MPE following failed previous drainage and pleurodesis. The cause of the effusion was breast cancer in 11 patients, lung cancer in 9, urogenital cancer in 3, mesothelioma in 2 and other in 2. VATS intervention was thoracoscopic exploration with biopsy and directed chemical sclerosis in undiagnosed MPE (19/27) and lysis of pleural adhesions with partial decortication and pleurodesis in recurrent effusions (8/27). VATS managements were successful 26/27 after mean follow up of 6 months. Had not mortality postoperatively and severe morbidity. Chest tubes were removed 1.5 +/- 0.5 days postoperatively and hospital stay were averaged 4 +/- 1 days. We concluded that VATS is a safety and effective way of managing selected patients with pleural effusions.     

Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients

Background. For effective palliation of patients with malignant pleural effusion due to advanced neoplastic disease, any proposed treatment should have low procedure-related mortality and morbidity.

Methods. The clinical outcome of 119 thoracoscopies in 101 patients (56 women, 45 men), from 42 to 91 years of age (mean, 68 ± 9 years) with malignant pleural effusions was evaluated in a retrospective study. Video-assisted thoracoscopy (VATS) talc pleurodesis was done in 105 instances, and a pleuroperitoneal shunt was performed 14 times as an alternative when complete expansion of the lung could not be achieved due to tumor implants on the visceral pleura.

Results. The VATS talc pleurodesis resulted in clinically significant improvement of dyspnea in 92.2% of the patients. Thirty-day mortality was 2.8% and morbidity was 2.8%. The mean duration of postoperative survival was 6.7 months. Recurrent pleural effusion occurred in 5.7% of patients after a mean interval of 6 months. Clinical relief of dyspnea was obtained in 73% of the patients treated with pleuroperitoneal shunts. Thirty-day mortality in this group was 21% and morbidity was 14.3%. The mean duration of survival was 4.2 months.

Conclusions. The VATS talc pleurodesis is appropriate for palliation of patients with malignant pleural effusions and should be performed once the diagnosis has been confirmed. Patients with lungs trapped by visceral carcinomatosis may benefit from placement of a pleuroperitoneal shunt as an alternative.     

Chemical pleurodesis to improve patients' quality of life in the management of malignant pleural effusions: the 15 year experience of the National Cancer Institute of Milan

We analyzed chemical pleurodesis role in recurrent neoplastic pleural effusions management, performed by two different techniques: VATS and minimal lateral thoracotomy. We compared the results obtained using the two different procedures, and we also evaluated the two sclerosing agents used (talc and alcohol). From January 1987 to March 2002, we treated 565 patients with malignant pleural effusion: 355 (63%) by VATS and 210 (37%) through mini-thoracotomy all of them underwent chemical pleurodesis: 442 (78%) by means of talc and 123 (22%) by alcohol. Chemical pleurodesis therapeutic success was globally obtained in 436 patients (77%). Dealing with surgical approaches, VATS reduced operating time (33 versus 44 minutes: P < 0.001), mean drainage time (3 versus 5 days: P < 0.001), complications (2% versus 7%: P = 0.006) and mean postoperative course (5 versus 7 days: P < 0.001). Therapeutic success of VATS-treated patients was 81% versus 65% of those undergoing thoracotomy (P < 0.001). We obtained a significantly lower relapse rate in the patients of all the two groups treated with talc versus alcohol (12% versus 35% in VATS group and 25% versus 59% in thoracotomic group). Our data indicate that chemical pleurodesis represents a good palliative treatment of neoplastic pleural effusion. Talc was superior to alcohol as sclerosant agent regardless of the surgical procedure. Comparing the two techniques, VATS should be preferred to minimal thoracotomy. We can suggest talc pleurodesis by VATS as the choice treatment in case of recurrent pleural effusions.     

Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis

The aim of the current study was to analyse postoperative complications and survival after video-assisted thoracoscopic (VATS) talc pleurodesis for malignant pleural effusion. All patients with morphologically proven malignant pleural effusion who underwent VATS talc pleurodesis from November 1995 to November 2002 were included in retrospective analysis. VATS was performed in general anaesthesia and 5 g of asbestos-free talc was insufflated into the pleural cavity. Postoperative pleural drainage was used until fluid output was less than 100 ml/24 h. Ninety-eight patients (28 male and 70 female) with mean age 59.6 (range 18-82) years were included. Thirteen patients had a bilateral pleural effusion. The most common primary cancer sites were lung (30 cases), breast (25) and ovarium (11). Average duration of the operation was 46 (range 10-120) min. Median duration of postoperative drainage was 3 (range 1-20) days and postoperative hospitalisation 7 (range 3-70) days. Twenty-eight patients had postoperative complications (fever in 17 cases). In seven cases pleurodesis was ineffective. Median survival was 8.4 months. Six-, 12- and 24-month survival was 58% (95% CI [0.47-0.67]), 39% [0.29-0.49] and 20% [0.12-0.29], respectively. Survival data after VATS talc pleurodesis advocate use of this invasive treatment method despite the advanced stage of cancer.     

Primary treatment of malignant pleural effusions: video-assisted thoracoscopic surgery poudrage versus tube thoracostomy

The objective of this study is to show that primary treatment of malignant pleural effusions secondary to ovarian carcinoma with video-assisted thoracoscopic surgery (VATS)-assisted talc poudrage (VATS-ATP) results in shorter hospital stays and reduced time with a chest tube than primary treatment with a chest tube and chemical pleurodesis. We conducted a retrospective chart review of all patients with a symptomatic pleural effusion secondary to primary ovarian carcinoma receiving intervention from January 1996 to December 2000. Patients either received tube thoracostomy with pleurodesis (n = 22) or VATS-ATP (n = 12). Of the patients treated with tube thoracostomy 18 per cent (4/21) died in the hospital before pleurodesis, 77 per cent (14/19) had successful pleurodesis, and 22 per cent (4/18) failed pleurodesis requiring VATS-ATP. In the group treated primarily with tube thoracostomy the chest tube was in place 8.36 +/- 2.61 days with a hospital stay of 12.64 +/- 5.80 days after the procedure. In the group treated with VATS-ATP there was 100 per cent successful pleurodesis. There were no mortalities. There was one prolonged intubation of 3 days and one incomplete lung reexpansion. The chest tube was in place for 4.58 +/- 1.78 days and a hospital stay of 7.50 +/- 4.12 days postprocedure. Groups treated by tube thoracostomy and VATS were statistically different; P < 0.001 for days with a chest tube and P = 0.011 for hospital days. We conclude that both tube thoracostomy with chemical pleurodesis and VATS-ATP provide adequate treatment of ovarian carcinoma-associated malignant pleural effusions. VATS-ATP provides a shorter duration of chest tube placement and postprocedure hospital stay.     

Talc pleurodesis in recurrent pleural effusions

Background and aims: The treatment of recurrent malignant pleural effusions is known to be difficult and varies from observation in asymptomatic patients to pleurectomy with varying results. This prospective study presents the efficacy and the limits of iodized talc pleurodesis in patients with malignant and non-malignant recurrent pleural effusions. Methods: In a prospective trial talc pleurodesis was performed in 50 patients with recurrent pleural effusions (malignant effusions: n = 36, non-malignant effusions: n = 14). After insertion of a chest tube and complete re-expansion of the lung, 5 mg of talc and 3 mg of thymol iodine were installed with 0.5 ml of 1% xylocaine/kg body weight and 30 ml 0.9% saline solution. The chest tube was removed after an average time of 4 days and chest radiographs were performed 1 month after instillation to evaluate the efficacy of pleurodesis. Results: Successful therapy was achieved in 31 of 33 patients (94%) with malignant effusions within a follow-up period of 7 months. Three patients died within 1 month after therapy due to progressive malignant disease. The treatment was successful in all cases of non-malignant effusions and complications did not occur in either group. Conclusions: These results indicate that pleurodesis with iodized talcum slurry is a simple and inexpensive method with high efficacy in controlling malignant and non-malignant pleural effusions. Received: 23 October 1997     

Single-incision thoracoscopic surgery of pleural effusions for diagnosis and treatment

Background

Several procedures such as video-assisted thoracoscopic surgery (VATS) are used to make a definite diagnosis in recurrent pleural effusions so that appropriate treatment can be arranged. Single-incision thoracoscopic surgery (SITS) is the most appropriate procedure that can be used for this purpose. The contribution of SITS to diagnosis and treatment is evaluated in this study that we conducted using a single thoracoport in patients with pleural effusion.

Methods

Nineteen consecutive patients with pleural effusion that was recurrent or refractory to medical treatment were included in the study to be diagnosed and treated with SITS. Thoracentesis was performed and pleural fluid samples obtained in all patients before the procedure. Pleural effusion drainage was performed from the 11-mm single skin incision by using a 10.5-mm single thoracoport, and biopsy or talc pleurodesis was performed in the same session when needed.

Results

The median age of the patients was 56.68 ± 3.05 years and there were 11 males and 8 females. The total amount of fluid drained by SITS was 1,436 ± 227 mL and the surgery lasted 81.05 ± 5.36 min. In addition, partial decortication and/or deloculation were performed in six patients and talc pleurodesis in nine patients. Fifteen patients were diagnosed with benign and four patients with malignant pleural effusion by thoracentesis, while nine patients were diagnosed with benign and ten patients with malignant pleural effusion by SITS. We therefore had six cases diagnosed as benign with thoracentesis who were diagnosed with malignant disease after SITS.

Conclusions

SITS presents both diagnosis and treatment options together for pleural effusions. We believe SITS should be preferred to conventional three-port VATS to minimize the spread of infection and tumor cells to the chest wall in infectious and malignant diseases.     

Thoracoscopic collagen pleurodesis in the treatment of malignant pleural effusions.

OBJECTIVE: Pleurodesis is of a potential benefit in pleural carcinomatosis and symptomatic malignant effusions, but the best way of achieving this is still uncertain. The aim of this prospective study was to analyse the results of pleurodesis after intra-pleural thoracoscopic administration of collagen powder. METHODS: 45 patients (19 men and 26 women; median age of 64 years, range from 36 to 73 years) with malignant pleural effusions underwent thoracoscopic collagen pleurodesis. The procedure involved thoracoscopic drainage of pleural effusion and intra-pleural insufflation of 1 g of bovine dermal collagen powder under general anaesthesia. Assessment of the immediate side effects and pH estimation of drained pleural fluid took place whilst inpatient. The patients were subsequently followed up for 1 year at 3-monthly intervals including outpatient clinical review and chest radiography. Prognostic value of pleural fluid pH in relation to the outcome of pleurodesis and patients' survival was statistically analysed. RESULTS: The procedure was well tolerated and there were no serious complications or deaths. Thoracoscopic collagen pleurodesis resulted in immediate resolution of malignant pleural effusion and all patients remained free of re-accumulated fluid for at least 1 month. Only 5 (11%) patients later developed recurrent effusion and required its repeat drainage at some point during the follow-up period. In the vast majority (89%) patients, thoracoscopic collagen pleurodesis proved successful in complete and permanent resolution of pleural fluid collection. Acid medium (pH < 7.3) of plural fluid was associated with poor survival (P < 0.05), but did not influence the clinical and radiological outcome of collagen pleurodesis (P > 0.05). CONCLUSIONS: Thoracoscopic collagen pleurodesis is a simple and effective method of treatment of malignant pleural effusions.     

Treatment of malignant pleural effusion by pleurodesis with talc

In some types of cancer (breast, lung) a malignant pleural effusion may be present during the evolution of the neoplastic disease in more than 50% of cases. The main therapeutic option for palliative purposes in these cases is chemical pleurodesis with talc. The aims of this study were to report on our experience with the use of pleurodesis with talc in the treatment of patients affected by malignant pleural effusions and to analyse the results in the short and mean term. Over the period from January 1998 to December 1999, 16 patients were included in the study. The causes of the pleural effusion were a pleural mesothelioma in 1 patient and pleural metastases in 15 patients (from lung and breast cancers in 62%). We treated 14 of these patients with talc poudrage and 2 patients with talc slurry. The talc was applied under video-assisted thorascopic management in 15 patients, while in 1 patient the talc was injected via the thoracic drainage tube. Two patients died within the first month as a result of progression of the neoplastic disease and one patient was withdrawn from the study owing to failure to collaborate. Of the other 13 patients, 11 (84%) had a total or partial response to the pleurodesis; in 9 of these patients (69.2%) the response remained stable until death, while in 2 patients the pleural effusion reappeared after 3 and 5 months, respectively. Failure of the pleurodesis occurred in 2/13 patients owing to reappearance of the pleural effusion within the first month.