电视胸腔镜辅助小切口行双侧肺减容术治疗重度肺气肿

目的:评价电视胸腔镜辅助小切口行双侧肺减容术治疗重度肺气肿的疗效,并总结围术期的处理经验。方法:回顾分析2006年以来为18例重度肺气肿患者实施肺减容术的临床资料,对比分析手术前后肺功能指标和动脉血氧分压的变化。结果:本组无手术死亡病例,2例合并急性呼吸衰竭。术后随访半年,平均第1秒用力呼气量增加39.2%,用力肺活量增加20.1%,残气量下降26.5%,肺总量下降23.1%,动脉血氧分压平均上升15.1%,与术前相比差异有统计学意义(P<0.05)。结论:电视胸腔镜辅助小切口行双侧肺减容术是经济有效的治疗方法,能明显改善重度肺气肿患者的临床症状和生理状况,增加活动能力。     

Thoracoscopy‐assisted mini‐open surgery for anterior column reconstruction in thoracic spinal tuberculosis

Objective: To evaluate the clinical effects of thoracoscopy‐assisted mini‐open surgery for anterior column reconstruction in thoracic spinal tuberculosis. Methods: Fifty‐eight patients, 35 men and 23 women, aged 39.2 (range, 19–60) years with thoracic spinal tuberculosis with an average kyphotic angle of 29.2° (range, 18°–42°) underwent thoracoscopy‐assisted mini‐open surgeries, including thorough debridement and anterior spinal reconstruction. According to the Frankel Grading system, preoperative neurological function was judged as Grade B in 3 cases, Grade C in 7, Grade D in 28, and Grade E in 20. All patients were followed up for an average of 4.6 years. Outcomes were evaluated retrospectively. Results: Surgery was accomplished successfully in all cases. The average operation time was 230 min (range, 180–320 min), the average intraoperative blood loss 570 ml (range, 350–1200 ml), and the mean drainage duration 3.6 days (3–5 days). Complications occurred in 19 patients (32.8%). Neurological improvement of one to three grades had occurred in 29 patients by final follow‐up. The average correction rate of the kyphotic angle was 36.4%, and no obvious correction loss was detected during follow‐up. No recurrent tuberculosis was found in the group. Conclusions: Thoracoscopy‐assisted mini‐open surgery provides a simple, safe, effective, and practical technology with minimal invasiveness for the treatment of thoracic spinal tuberculosis.     

Mediastinal hyperfunctioning parathyroids: incidence, evolving treatment, and outcome

BACKGROUND: The evaluation and treatment of hyperfunctioning mediastinal parathyroid gland(s) (MPG) is evolving. This study reports our overall experience with MPG in a tertiary referral center. METHODS: A prospective database of 922 patients undergoing parathyroidectomy by 2 surgeons from 1982 to 2005 was reviewed. RESULTS: Thirty-two of 922 (3.5%) patients had MPG. Nine (28%) patients had a prior failed parathyroidectomy. Sestamibi and computed tomography scans were correctly positive in 24/28 (86%) and 6/7 (86%) patients, respectively. MPGs were removed via cervical approach in 22 (69%). Eleven of 22 patients had a focused cervical approach. Nine MPGs required a limited sternotomy (n = 3) or a successful radioguided video-assisted thoracoscopic approach (VATS, n = 4) for removal. Two VATS were converted to a full sternotomy. One patient refused surgery. All patients who required sternotomy/VATS had MPGs caudal to the innominate vein. Twenty-nine of 31 (94%) patients were cured. Two are stable on calcimimetics. One patient has permanent hypoparathyroidism. CONCLUSIONS: Most MPGs can be removed through a cervical approach. Preoperative Sestamibi and computed tomography scans can help the surgeon plan the best initial surgical approach. Those below the innominate vein require a thoracic procedure, preferably a radioguided probe-assisted thoracoscopic resection with intraoperative parathyroid hormone (ioPTH). An alternative to surgical removal is medical treatment.     

Carbon dioxide suppresses macrophage superoxide anion production independent of extracellular pH and mitochondrial activity

Background

Superoxide anions released by activated macrophages during surgery are considered to be responsible for local cellular damage. Application of CO₂ pneumoperitoneum during laparoscopy affects superoxide anion release, but the underlying mechanism remains unclear and the data reported are conflicting. We investigated the direct and pH-mediated impact of CO₂ and air on macrophage superoxide anion production.

Methods

Cells of the NR 8383 rat macrophage cell line were incubated for 2 hours in 5% CO₂, 100% CO₂, and room air or pH 7.4, pH 6.5, and pH 5.5. The extracellular pH was monitored during incubation. At 0, 2, and 6 hours after incubation, the release of superoxide anions was determined fluorometrically. The mitochondrial activity was determined via the conversion of MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] during and after incubation.

Results

Extracellular pH decreased to 6.4 during incubation in a CO₂ atmosphere. The release of superoxide anions was significantly reduced immediately after CO₂ incubation. It was restored at all other time-points. Decreasing the extracellular pH to 6.5 had no effect on superoxide anion release, whereas acidification of the extracellular milieu to pH 5.5 significantly suppressed subsequent superoxide release. Mitochondrial activity was significantly decreased by CO₂ up to 2 hours and by acidic milieu up to 6 hours. Incubation in room air had no effect.

Conclusions

Incubation in CO₂ can directly suppress macrophage superoxide anion production. This effect is of short duration, fully reversible, and not correlated to changes in extracellular pH or mitochondrial activity. Air contamination does not affect macrophage superoxide anion release. We speculate that CO₂ pneumoperitoneum could attenuate the intraoperative free radical production by directly inhibiting superoxide anion release of macrophages without long-lasting suppression of macrophages and their capacity to release superoxide anions postoperatively.     

可弯曲内科胸腔镜在恶性胸腔积液中的诊断价值

目的:评估可弯曲内科胸腔镜在恶性胸腔积液诊断中的应用价值。方法:对2007年10月-2010年6月的32例恶性胸腔积液患者行可弯曲内科胸腔镜检查的结果进行回顾性分析。所有患者在行内科胸腔镜检查前,其胸腔积液常规、生化、微生物学及细胞学等实验室检查均未能明确病因。结果:32例恶性胸腔积液患者中肺癌28例(腺癌22例、低分化癌6例),淋巴瘤2例,恶性胸膜间皮瘤2例。术后发热1例,未发生其他严重不良事件。结论:可弯曲内科胸腔镜是一种操作简便、安全而有效的诊断方法。对经其他常规检查无法明确诊断,且临床不能排除恶性胸腔积液时,应及时行内科胸腔镜检查以明确诊断。     

Intradiaphragmatic extralobar sequestration—a rare pulmonary anomaly

Extralobar pulmonary sequestrations are most commonly found within the thoracic cavity, but have been described within the abdomen. We present the case of a 16-month-old boy with an intradiaphragmatic pulmonary sequestration and demonstrate a computed tomographic scan finding that might help identify this extremely rare abnormality preoperatively.     

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.     

Thoracoscopic patch repair of a right-sided congenital diaphragmatic hernia in a neonate

Purpose  Minimally invasive techniques continue to expand in pediatric surgery; however, there has been some debate over the appropriate operative technique for the management of congenital diaphragmatic hernias in neonates [1–3]. We present a video of a thoracoscopic patch repair of a right-sided Bochdalek congenital diaphragmatic hernia (CDH) in a 3-day-old male. Methods  Our patient was noted to have a right-sided CDH on chest X-ray following respiratory distress at the time of birth. The patient’s remaining neonatal workup also confirmed hypoplastic transverse aortic arch with coarctation, ventricular septal defect (VSD), and patent ductus arteriosus, which were initially diagnosed by prenatal ultrasound. After monitoring the patient for hemodynamic stability and discussion with the family and involved pediatric cardiothoracic surgeons, the decision was made to proceed with a thoracoscopic repair of the CDH. Results  The large right-sided CDH was noted to involve herniated small bowel, colon, and liver. The diaphragmatic defect was successfully repaired thoracoscopically using a 5 × 5 cm polytetrafluoroethylene (PTFE) patch. The patient was extubated on the second postoperative day and ultimately underwent aortic arch augmentation, VSD closure, and patent ductus arteriosus ligation and division at 1 month of age. There has been no evidence of CDH recurrence in follow-up. Conclusions  As demonstrated by our video, large right-sided congenital diaphragmatic hernias requiring patch repair can be successfully repaired thoracoscopically with appropriate surgeon comfort and experience. This minimally invasive approach may also be used in neonates with associated cardiac defects with appropriate cardiothoracic surgical consultation and support. To our knowledge this is the first reported case of a thoracoscopic repair of a Bochdalek (posterolateral) hernia with a prosthetic patch in a neonate with significant congenital cardiac anomalies. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

经右胸前侧入路电视胸腔镜下胸腺切除治疗重症肌无力

目的 探讨经右胸前侧入路电视胸腔镜手术(VATS)胸腺切除治疗重症肌无力(MG)的可行性及疗效.方法 回顾性分析2001年8月至2007年10月采用经右胸前侧入路VATS胸腺切除治疗MG的56例患者的临床资料.结果 55例患者通过VATS顺利完成胸腺(或胸腺瘤)与前纵隔脂肪切除.平均手术时间(96.2±52.1)min,平均术中出血量(68.7±21.4)ml.2例患者术中发生左头臂静脉损伤;1例术中结扎止血,1例中转开胸止血后完成手术.切除胸腺及纵隔脂肪组织平均(22.1±9.2)g.术后病理检查示胸腺增生38例,胸腺萎缩5例,胸腺瘤12例,胸腺囊肿1例.1例(1.8%)患者因出血于术后第8天死亡.1例(1.8%)患者术后发生重症肌无力危象.平均住院时间(7.9±2.9)d.术后MG完全缓解8例(14.3%),部分缓解39例(69.6%),无变化7例(12.5%),总有效率83.9%.结论 利用VATS经右胸前侧入路行胸腺切除安全可行,治疗MG效果满意.     

First decade's experience with thoracoscopic lobectomy in infants and children

Purpose

This study evaluates the safety and efficacy of thoracoscopic lobectomy in infants and children.

Methods

From January 1995 to March 2007, 97 patients underwent video-assisted thoracoscopic lobe resection. Ages ranged from 2 days to 18 years and weights from 2.8 to 78 kg. Preoperative diagnosis included sequestration/congenital adenomatoid malformation (65), severe bronchiectasis (21), congenital lobar emphysema (9), and malignancy (2).

Results

Of 97 procedures, 93 were completed thoracoscopically. Operative times ranged from 35 minutes to 210 minutes (average, 115 minutes). There were 19 upper, 11 middle, and 67 lower lobe resections. There were 3 intraoperative complications (3.1%) requiring conversion to an open thoracotomy. Chest tubes were left in 88 of 97 procedures for 1 to 3 days (average, 2.1 days). Hospital stay ranged from 1 to 12 days (average, 2.4 days).

Conclusions

Thoracoscopic lung resection is a safe and efficacious technique. It avoids the inherent morbidity of a major thoracotomy incision and is associated with the same decrease in postoperative pain, recovery, and hospital stay as seen in minimally invasive procedures.