Video-assisted thoracic surgery for bronchopulmonary sequestration

Bronchopulmonary sequestration is a rare congenital lung anomaly for which surgical resection is the definitive treatment. Open thoracotomy is the conventional approach, yet associated with considerable morbidity. We report one of the largest series of major lung resection for bronchopulmonary sequestration using the video-assisted thoracic surgery (VATS) approach that could reduce such morbidity. Six cases of VATS anatomical lobectomy for intrapulmonary sequestration performed between January 1996 and January 2005 were reviewed. The six patients included two males and four females, with a mean age of 43.3 years (range: 27-64 years). Anatomical lobectomy without conversion to open was achieved in all cases. The mean operating time was 112.8 min (range: 90-140 min), the mean blood loss was 283.3 ml (range: 100-500 ml), and the mean length of post-operative hospital stay was 8.8 days (range: 7-24 days). There was no mortality. Three patients had minor wound infection. The results were comparable patients receiving lung resections for bronchopulmonary sequestration by an open approach. VATS major lung resection for bronchopulmonary sequestration is safe and feasible. Further studies are warranted to define the role of VATS in the management of bronchopulmonary sequestration.     

Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery

BACKGROUND: The National Emphysema Treatment Trial, a randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema, included randomized and nonrandomized comparisons of the median sternotomy and video-assisted thoracoscopic approaches for lung volume reduction surgery. METHODS: Lung volume reduction surgery was performed by median sternotomy only at 8 centers and video-assisted thoracoscopy only at 3 centers; 6 centers randomized the approach to lung volume reduction surgery. Mortality, morbidity, functional status, and costs were assessed. RESULTS: In the nonrandomized comparison, 359 patients received lung volume reduction surgery by median sternotomy, and 152 patients received lung volume reduction surgery by video-assisted thoracoscopy. The 90-day mortality was 5.9% for median sternotomy and 4.6% for video-assisted thoracoscopy (P =.67). Overall mortality was 0.08 deaths per person-year for median sternotomy and 0.10 deaths per person-year for video-assisted thoracoscopy (video-assisted thoracoscopy-median sternotomy risk ratio, 1.18; P =.42). Complication rates were low and not statistically different for the 2 approaches. The median hospital length of stay was longer for median sternotomy than for video-assisted thoracoscopy (10 vs 9 days; P =.01). By 30 days after surgery, 70.5% of median sternotomy patients and 80.9% of video-assisted thoracoscopy patients were living independently (P =.02). Functional outcomes were similar for median sternotomy and video-assisted thoracoscopy at 12 and 24 months. Costs for the operation and the associated hospital stay and costs in the 6 months after surgery were both less for video-assisted thoracoscopy than for median sternotomy (P <.01 in both cases). Similar results were noted for the randomized comparison. CONCLUSIONS: Morbidity and mortality were comparable after lung volume reduction surgery by video-assisted thoracoscopy or median sternotomy, as were functional results. The video-assisted thoracoscopic approach to lung volume reduction surgery allowed earlier recovery at a lower cost than median sternotomy.     

Initial experience of video-assisted thoracic surgery lobectomy with partial removal of the pulmonary artery

A lobectomy with a resection of the pulmonary artery is less invasive than a pneumonectomy. However, it seems to be extremely difficult to perform this technique using video-assisted thoracic surgery with technical limitations because this technique is associated with an increased operative risk even in an open thoracotomy. Between April 2002 and December 2006, a curative video-assisted thoracic surgery lobectomy including a mediastinal lymphadenectomy was performed in 121 patients with primary non-small cell lung cancer. Five of those patients underwent a thoracoscopic lobectomy with the partial removal and reconstruction of the pulmonary artery. The causes of the pulmonary artery resection included two direct invasions of the artery, two invasions of the arterial branch, and one calcified lymphadenopathy involving the branch. No patients required a blood transfusion. No complications attributable to the technique or mortality were seen. No patients showed an abnormal blood flow through the reconstructed vessel. There were no local recurrences on the pulmonary artery. A video-assisted thoracic surgery lobectomy including a partial resection and reconstruction of the pulmonary artery is a complex procedure for patients with non-small cell lung cancer. It is feasible when all associated technical issues are properly addressed.     

Video-assisted thoracic lobectomy with bronchoplasty for lung cancer, with special reference to methodology

Few studies have described video-assisted thoracic surgery (VATS) to bronchoplasty with pulmonary resection. Here, we report the successful implementation of VATS bronchoplasty, as determined retrospectively. Between 2005 and 2010, 362 patients underwent elective lung resection for malignant or benign lung tumors. Of these patients, VATS lobectomy with bronchoplasty was performed in seven patients (four men, three women; median age, 72.9 years). The medical records were retrospectively reviewed. Of the seven patients, six had primary lung cancer (PLC), and one had metastatic cancer of the lung. The surgical procedures were lobectomy with wedge bronchoplasty. The patients with PLC also underwent mediastinal or hilar lymph node dissection. The median total operating time was 230 min, and the median blood loss was 152 ml. The median postoperative hospital stay was seven days, without major postoperative complications. The most important feature of the described method is that the surgeon mainly observes the operative field directly, through a working wound; the surgical team observes via a monitor. An advantage for the surgeon is the ability to use the same instruments in VATS as are used in conventional thoracotomy, as well as the same suturing techniques in vascular reconstruction, especially involving the pulmonary artery.     

机器人辅助胸腔镜肺叶切除12例临床分析

目的探索应用daVinciS机器人辅助胸腔镜进行肺叶切除术的安全性、手术效果及在微创手术中的优势。方法2009年5月至2013年5月,上海市胸科医院应用daVinciS机器人辅助胸腔镜对12例临床拟诊为非小细胞肺癌（NSCLC）患者行肺叶切除术,男6例、女6例,年龄40～61（52±8）岁。所有手术通过1个12mm观察孔、2个8mm操作孔和1个12～40mm辅助切口完成,肋骨不撑开。收集分析患者同手术期资料。结果全组12例手术均获成功,包含所有位置肺叶切除,均系完全性切除,清扫淋巴结4～9（5±1）组,无中转开胸。所有患者均未发生围术期并发症或死亡。胸腔引流管引流时间3～11（8＋7）d,住院时间6～18（14＋8）d,手术时间60～280（185±78）min,术中出血量20～200（108±71）m1,围术期均未输血。结论机器人辅助胸腔镜肺叶切除术初步证明安全有效,电视胸腔镜有更逼真的视野、更灵活稳定的操作,从而具备更宽泛的手术适应证,是新一代微创胸部手术的重要选择。     

A method of assessing reasons for conversion during video-assisted thoracoscopic lobectomy

Conversion rates during video-assisted thoracoscopic lobectomy are reported, but no previous publications have classified the cause of conversion. The aim of the study was to develop a quality assessment tool [vascular, anatomy, lymph node, technical (VALT) 'Open'] to evaluate reasons and nature of conversion during the development of a video-assisted thoracoscopic lobectomy program. Between 2006 and 2008, 237 patients with a median age of 65 years underwent video-assisted thoracoscopic lobectomy primarily for lung. The number of video-assisted thoracoscopic lobectomy cases over open cases has increased over the period. Conversion rate has dropped from 15% (2006) to 11% (2008). A total of 32 cases required conversion. The VALT 'Open' classification for reason to convert and nature of conversion was used. The average length of stay was shorter for non-converted cases. No uncontrolled conversions where the patient was unstable were required, and in the 14 cases converted following some difficulty, such as pulmonary artery injury. A pattern to the learning curve became predictable. The quality assessment tool used (VALT 'Open') will allow cause of conversion and nature of conversion to be tracked and audited during the development of a video-assisted thoracoscopic surgery lobectomy program.     

胸腔镜辅助小切口肺血管-支气管成形术治疗中央型肺癌139例分析

目的探讨胸腔镜辅助小切口和常规后外侧切口在肺血管-支气管成形术治疗中央型肺癌中的可行性及效果。方法对广州医学院第一附属医院1995年1月至2007年7月139例采用胸腔镜辅助小切口术式及四川大学华西医院2000年4月至2005年12月99例采用常规后外侧切口术式的因病变涉及肺叶开口或肺动脉,而行肺血管-支气管成形术患者的临床资料进行回顾性分析。结果两组患者均顺利完成手术,无围手术期死亡,术后无吻合口狭窄、吻合口瘘及切缘癌细胞残留。胸腔镜辅助小切口组平均生存时间为63．17个月,常规后外侧切口组为42．00个月,术后生存率无明显差异。肺动脉成形患者的保留肺叶无肺再灌注损伤或明显肺水肿征象。胸腔镜辅助小切口组辅助切口的平均长度为10cm,常规后外侧切口组切口平均长度为30cm。胸腔镜辅助小切口组手术时间、术后胸管留置时间及住院时间均短于常规后外侧切口组,术后患侧肩关节功能障碍发生率低。结论利用胸腔镜辅助小切口施行肺血管一支气管成形术,不仅具有与常规后外侧切口相同的适应证和术后生存率,而且在减小手术创伤,促进患者恢复方面具有优势。     

Video-assisted thoracic surgery (VATS) lobectomy: 13 years’ experience

BACKGROUND: Major lung resection by video-assisted thoracic surgery (VATS) has been proven to be both safe and technically feasible, but is not routinely performed in most hospitals. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained. METHODS: We have performed a retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit, Virgen Macarena University Hospital, Seville (Spain) since 1992. The clinical records of all patients were drawn from the hospital archive and data for the following variables were recorded for analysis: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications, postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. We also describe our surgical technique for each lobectomy. RESULTS: A total of 237 major pulmonary resections were performed, on 203 males and 34 males, with a mean age of 61.43 years (non-small-cell bronchogenic carcinoma: 204, benign processes: 24, carcinoid tumors: 4, and lobectomy due to metastases: 5). The overall conversion rate was 14.01%. Mean duration of lobectomy was 153 min, with a median of 98 min, and mean postoperative stay was 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications. Perioperative mortality was 3.7%. The actuarial 5-year survival rate was 77.7%. CONCLUSIONS: VATS lobectomy is a viable safe procedure that meets oncological criteria for lung cancer surgery. In our experience, VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas.     

Video-assisted thoracic surgical resection of malignant lung tumors.

Forty patients with malignant pulmonary disease underwent evaluation, staging, and a biopsy or resection by means of video-assisted thoracic surgery. There were 20 men and 20 women whose ages ranged from 27 to 82 years. Eight patients had a wedge resection for metastatic carcinoma, three a lobectomy for primary carcinoma, six exploration of the thorax, five biopsy of the aortopulmonary window, and eighteen a sublobar resection for primary carcinoma of the lung. There was no mortality. Three patients had air leaks that lasted an average of 8 days. Video-assisted thoracic surgery seems to be useful for more precise staging of carcinoma of the lung, and, in some patients, resectional operations can be performed.     

Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy

BACKGROUND: Resection of the portal/superior mesenteric vein (PV/SMV) during pancreatoduodenectomy (PD) is disputed. Although morbidity and mortality are acceptable, survival is limited after PV/SMV resection. In this study, we evaluate the effect of PV/SMV resection. METHODS: Between 1992 and 1998, there were 215 consecutive patients who underwent PD for malignant disease. Thirty-four patients underwent a PV/SMV resection. Resection was only performed when minimal venous ingrowth was found perioperatively. Surgical techniques, perioperative parameters, and survival were analyzed. RESULTS: The percentage of PV/SMV resections was 16%. Extensive (segment) resections were performed in 6 patients. The median blood loss was 1.8 L and resection margins were microscopically tumor free in 41% of the patients. The median hospital stay was 15 days, and mortality was 0%. Median survival after PV/SMV resection for pancreatic adenocarcinoma was 14 months. CONCLUSIONS: Limited PV/SMV resection for perioperatively encountered minimal venous ingrowth during PD can be performed safely without increased morbidity and mortality but also results in a high frequency of tumor-positive resection margins.     

Radical en bloc resection for lung cancer invading the spine

OBJECTIVE: We reviewed our 8-year experience with en bloc partial and total vertebrectomy for lung cancer invading the spine and report outcome and survival. METHODS: Nineteen patients with lung cancers involving the spine underwent en bloc resection. Eleven received induction treatment (chemotherapy, n = 5; chemoradiotherapy, n = 4; and radiation, n = 2). Pneumonectomy was performed in 3 patients, lobectomy in 13 patients, and wedge resection in 3 patients. Hemivertebrectomy was performed in 15 patients, and total vertebrectomy was performed in 4 patients. The median number of resected vertebral bodies was 3 (range, 1-4). Tumor stage was IIIB in 14 patients, IIIA in 1 patient, and IIB in 4 patients (hemivertebrectomy is performed in the case of T3 disease to obtain free margins). Surgical nodal status was N0 in 13 patients, N1 in 3 patients, N2 in 1 patient, and N3 (supraclavicular) in 2 patients. Complete macroscopic and microscopic resection was achieved in 15 (79%) patients. RESULTS: There was no immediate postoperative mortality. Morbidity was observed in 10 patients, including 4 (21%) complications related to the spinal surgery. The median hospital stay was 30 days. Seven patients were alive after a mean follow-up of 26 months (range, 7-74 months). The 1- and 5-year predicted survivals (updated) are 59% and 14%, respectively. Nine local recurrences were observed. CONCLUSIONS: En bloc resection of chest tumors with vertebrectomy is technically demanding, and postoperative morbidity should be critically addressed with this aggressive surgical intervention. However, an encouraging long-term survival observed in this series suggests that en bloc resection could be a valid option in selected patients with vertebral involvement of chest tumors.     

Operative management and outcomes of traumatic lung resection

BACKGROUND: To analyze the presentation, injury patterns, and outcomes among a large cohort of patients requiring lung resection for trauma, and to compare outcomes stratified by the extent of resection. STUDY DESIGN: Review of all adult patients undergoing lung resections in the National Trauma Data Bank. Patients were categorized by extent of lung resection; wedge resection, lobectomy, or pneumonectomy. Patient factors, injury data, and outcomes were compared between groups using univariate and multivariable analysis for the entire sample, and after excluding patients with severe associated injuries. RESULTS: There were 669 patients who had a lung resection after trauma identified for an overall prevalence of 0.08%, with 325 undergoing wedge resection (49%), 244 had a lobectomy (36%), and 100 underwent complete pneumonectomy (15%). Blunt mechanism was associated with worse outcomes in terms of prolonged hospital stay, complications, disability, and a trend toward higher mortality (38% versus 30%, p = 0.07). Patients undergoing pneumonectomy had a higher mortality (62%) and more complications (48%) compared with patients undergoing lobectomy (35% mortality, 33% complications) and wedge resection (22% and 8%, all p < 0.05). After excluding patients with severe associated injuries (head, abdomen, heart, great vessels), there were 535 patients with "isolated" lung injury. There was again a stepwise increase in mortality by extent of resection, 19% for wedge resection, 27% for lobectomy, and 53% for pneumonectomy. Extent of lung resection remained an independent predictor of mortality for both the entire sample and for patients with isolated lung injury. CONCLUSIONS: Lung resection is infrequently required for traumatic injury, but carries substantial associated morbidity and mortality. The extent of lung resection is an independent predictor of hospital mortality, even after exclusion of patients with severe associated injuries. The worst outcomes were seen after complete pneumonectomy.     

胸腔镜辅助小切口手术诊治肺周围型结节

目的探讨胸腔镜辅助小切口手术在诊断和治疗肺周围型结节病变中的临床应用价值。方法胸腔镜辅助小切口手术诊治肺周围型结节55例，其中单发结节54例，多发结节1例。肺楔形切除术23例；肺叶切除联合淋巴结清扫治疗原发性肺癌32例，采用常规开胸手术器械及胸腔镜用器械切除肺叶，自制淋巴结摘除钳完成淋巴结清扫。结果55例均在胸腔镜下完成手术。手术时间35～180min，平均109min，术中出血量50～400ml，平均122min。均未输血，1例术后漏气术后32d出院，1例切口延迟愈合，术后19d出院，余53例术后住院4～11d，平均8．3d。无严重并发症。术后病理：良性病变15例，原发性肺癌38例，非典型性腺瘤样增生1例，转移性肺癌1例。良性病变行肺楔形切除术，32例原发性肺癌行解剖学肺叶切除联合淋巴结清扫，4例肺癌胸膜广泛播散未手术处理，2例肺癌因肺功能差行姑息性肺楔形切除。结论胸腔镜辅助小切口手术有助于明确诊断肺周围型结节病变，治疗临床早期原发性肺癌的长期疗效有待随访观察。     

Video-assisted lobectomy in elderly lung cancer patients

OBJECTIVES: We evaluated the pre-, intra- and postoperative outcome of video-assisted thoracic surgery lobectomy in elderly lung cancer patients to determine what factors may be disadvantageous. METHODS: From June 1982 to May 2000, 707 patients underwent pulmonary resection for primary lung cancer. Of these, 87 patients with t1-2 peripheral lung cancer underwent lobectomy and postoperative pulmonary function tests and postoperative conditions at an average of 2.3 months postoperatively. Of these, 52 underwent video-assisted thoracic surgery lobectomy since 1994 and 35 lobectomy by standard thoracotomy. RESULTS: Video-assisted thoracic surgery lobectomy offered advantages in blood loss, chest wall damage, and minimal performance deterioration status. The percent vital capacity, percent forced expiratory in 1 second, and percent maximum ventilatory volume were well preserved in patients who underwent video-assisted thoracic surgery lobectomy. Multivariate logistic regression analysis identified operation duration as an independent risk factor in morbidity and operative procedure as an independent risk factor in performance deterioration. In stage IA and IB patients, 3-year-survival was 92.9% and 5-year survival 53.8% in those undergoing lobectomy by standard thoracotomy and 84.2% at 3 years and 60.1% at 5-years in those undergoing video-assisted thoracic surgery lobectomy. CONCLUSION: We thus consider video-assisted thoracic surgery lobectomy in this age group to be an effective procedure, but the long surgical duration is a risk factor in a poor clinical outcome.     

Surgical treatment of pulmonary metastases from colon and rectal cancer

We retrospectively studied the surgical treatment for pulmonary metastases from colon and rectal cancer. A total of 24 patients (9 males and 15 females; mean age 61 years) underwent 29 thoracotomies for metastatic colon carcinoma, while 22 patients (16 males and 6 females; mean age 63 years) underwent 29 thoracotomies for metastatic rectal cancer. The median interval between the primary procedure and lung resection for metastases was 26 months in the patients with colon carcinoma and 32 months in the patients with rectal cancer. In the patients with colon carcinoma, 16 underwent wedge resection or segmentectomy (including 4 video-assisted procedures) and 13 (54%) underwent lobectomy or pneumonectomy. In the patients with rectal cancer, 15 underwent wedge or segmentectomy (including 1 video-assisted procedure), 13 (59%) underwent lobectomy or pneumonectomy, and 1 underwent exploratory thoracotomy. All procedures except exploratory thoracotomy were curative operations. There was no mortality. Overall 5-year survival was 56% (n=46). Five-year survival was 65% for patients with colon metastases (n=24) and 45% for patients with rectal metastases (n=22), and there was no significant difference. Recurrent sites were 4 lungs (36%), 4 livers (36%), 1 bone, 1 uterus, and 1 peritoneum in patients with colon carcimoma, and 10 lungs (43%), 5 brains (22%), 3 livers (13%), 1 bone, and 1 vagina in patients with rectal cancer. Pulmonary resection for metastases from colon carcinoma may have better prognosis than that from rectal cancer. However, further investigation may be required to obtain convincing conclusions.     

全胸腔镜支气管袖式/成形肺叶切除治疗中央型肺癌120例

目的探讨胸腔镜支气管袖式/成形肺叶切除治疗中央型肺癌的安全性、有效性。方法2016年4月~2019年8月我院行胸腔镜支气管袖式/成形肺叶切除治疗中央型肺癌120例,采用三孔法,先行系统性淋巴结清扫,然后行解剖性肺叶切除,最后行支气管切除吻合。结果110例完成全胸腔镜支气管袖式/成形肺叶切除(支气管袖式切除86例,支气管楔形切除成形24例);10例中转开胸(8.3%):肺门叶间淋巴结钙化4例,肿瘤侵犯肺动脉干4例(2例中转为左全肺切除),术中大出血2例。手术时间115~440 min,中位数210 min;出血量50~1000 ml,中位数200 ml。术后平均带管5.8 d(2~34 d),平均住院6.6 d(3~35 d)。术后病理:非小细胞不明类型肺癌2例,鳞癌91例,腺癌13例,混合癌3例(鳞癌为主),神经内分泌癌2例,腺样囊性癌、肉瘤样癌、类癌、肺母细胞瘤、黏液表皮样癌各1例,小细胞肺癌4例。无围手术期死亡,3级以上并发症(Clavien分级)11例(9.2%),包括肺部感染支气管镜吸痰4例(2例呼吸衰竭经历ICU过渡治疗),胸壁皮下气肿行胸腔闭式引流6例,支气管吻合口漏二次手术1例。新辅助化疗后19例中,2例发生3级以上术后并发症(均为皮下气肿置管引流)。113例随访1~41个月,中位随访时间20个月,非肿瘤死亡1例,全身广泛转移死亡11例,Kaplan-Meier生存分析1、2、3年累积生存率分别是98.9%、90.7%、85.4%。结论全胸腔镜支气管袖式/成形肺叶切除治疗包含部分局部晚期的中央型肺癌安全有效,新辅助化疗不额外增加手术风险,值得临床推广。     

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.     

Portal vein resection and reconstruction prior to hepatic dissection during right hepatectomy and caudate lobectomy for hepatobiliary cancer

BACKGROUND: Hepatobiliary cancer invading the hilar bile duct often involves the portal bifurcation. Portal vein resection and reconstruction is usually performed after completion of the hepatectomy. This retrospective study assessed the safety and usefulness of portal vein reconstruction prior to hepatic dissection in right hepatectomy and caudate lobectomy plus biliary reconstruction, one of the common procedures for radical resection. METHODS: Clinical characteristics and perioperative results were compared in patients who underwent right hepatectomy and caudate lobectomy plus biliary reconstruction with (ten patients) and without (11 patients) portal reconstruction from September 1998 to March 2002. RESULTS: All ten portal vein reconstructions were completed successfully before hepatic dissection; the portal cross-clamp time ranged from 15 to 41 (median 22) min. Blood loss, blood transfusion during the operation, postoperative liver function, morbidity and length of hospital stay were similar in the two groups. No patient suffered postoperative hepatic failure or death. CONCLUSION: This study demonstrates that portal vein reconstruction does not increase the morbidity or mortality associated with right hepatectomy and caudate lobectomy with biliary reconstruction. This approach facilitates portal vein reconstruction for no-touch resection of hepatobiliary cancer invading the hilar bile duct.     

Laparoscopically assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients.

PURPOSE: The objectives of this study were to refine the technique of laparoscopically assisted anterior resection (LAR) for diverticular disease and to analyze the morbidity and mortality rates, and longer term follow-up of the first 100 consecutive patients. METHODS: Data were collected prospectively, and follow-up was performed by an independent assessor using a standardized questionnaire. RESULTS: The median duration of surgery was 180 minutes, the median time for passage of flatus was 2 days after surgery, and the median length of hospital stay was 4 days. Overall, the morbidity rate was 21%, and the wound infection rate was 5%. There were no deaths. Eight patients underwent open laparotomy. The rate of complications was significantly greater in the latter group of patients (75%) than in those who underwent laparoscopy (16%, p = 0.002). The comparison between the first 20 cases and the last 20 patients revealed a significantly shorter duration of surgery (median 225 min. vs. 150 min.; p < 0.0001) and decreased length of stay (6 days vs. 4 days, p < 0.0001). Apart from a nonsignificant increase in the length of surgery, there were no differences in other study parameters when comparisons were made between those patients who underwent LAR for complicated diverticular disease and those patients who underwent uncomplicated diverticular disease. FOLLOW-UP: Ninety patients were available for follow-up at a median time of 37 months. Ninety-three percent of the patients reported that the surgery had improved their symptoms. No patient required hospitalization, and no one was treated with antibiotics for recurrent symptoms. CONCLUSION: Laparoscopically assisted anterior resection for diverticular disease has acceptable morbidity and mortality rates and a median postoperative hospital stay of only 4 days. Follow-up investigations revealed no recurrence of diverticulitis, and patients reported satisfaction regarding cosmetic and functional results.     

CONCOMITANT CORONARY REVASCULARIZATION AND RESECTION OF LUNG CANCER

As age and smoking are common risk factors, patients with lung cancer frequently have coexistent ischaemic heart disease. Ignoring the coronary disease results in an unacceptable operative mortality, whilst sequential coronary grafting and lung resection may prejudice the results of the resection. A series of 10 patients underwent combined coronary revascularization (average 2.9 grafts per patient) and lung resection for carcinoma (seven lobectomies, one bilobectomy, one sleeve lobectomy, and one pneumonectomy). The majority of patients had unstable angina, triple vessel or left main coronary artery stenosis and poorly staged tumours. There was no operative mortality and the average hospital stay was 20 days. Half the patients had significant peri-operative morbidity; seven are alive and well at between 12 and 38 months follow-up; but three have died of recurrent carcinoma (one with associated sepsis) at 3,8, and 13 months. Combined coronary revascularization and lung resection can be safely performed in selected patients. The early morbidity is mainly related to the cardiac procedure and impaired respiratory function preoperatively, but the long-term results are dependent upon the control of the lung carcinoma.