[Contrivance for video-assisted thoracic surgery pulmonary resection; a new-shaped rib spreader and one port operatinon]

A new-shaped rib spreader, which was adapted from a ready-made reverse arch rib spreader, was orderd to consist of inverted-Y-shape blades which were 4 cm in length, 3.7 cm in width and bent at 250 angle with each other at the half of length. This rib spreader with long and angled blades make it possible to perform video-assisted thoracic surgery (VATS) lobectomy and segmentectomy with 4-5 cm access incision and only 1 port for almost all of the patients inclusive of a thick chest wall case. A lung grasping forceps and a thoracoscope together were inserted from the same port insicion. The surgeon operates by watching both monitoring vision and direct vision through the access incision. Pulmonary artery (PA) s were ligated by double tied and transfixion suture with silk threads. Pulmonary vein (PV) s and bronchus were stapled and divided with Endo-GIA. Lymph nodes division was performed for ND2a-2b in right side, however, ND2a in left side. These thoracoscopic pulmonay resectional procedure can be performed safely, certainly, cosmeticaly and for reducing cost.

[Video-assisted thoracic surgery lobectomy for lung cancer: combination of less invasion and universality]

Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive technique for treatment of lung cancer, but is still only performed in a few specialized centers around the world. Therefore in a hospital, where only one experienced thoracoscopic surgeon exists, a safe and less invasive surgery is required. From January 2001 to July 2008, we performed 316 VATS lobectomies, in which the special VATS of 163 cases were included. The procedure was based on a mini-thoracotomy with rib spreading under the condition of 2 skin incisions of 5 cm and 1 cm on axillar part. This method is probably less invasive than our former procedure. Coping with both universality and less invasion is requested in provincial hospitals.

[Approaches and results in video-assisted thoracic surgery lobectomy for the patient with primary lung cancer]

Video-assisted thoracic surgery (VATS) lobectomy is defined as a video-assisted procedure using anatomic dissection with individual ligation of the vessels and bronchi. VATS lobectomy can offer several advantages, including decreased pain, and decreased inflammatory response. The patient is placed in the lateral decubitus position. A 12-mm port is inserted in the 7th intercostal space at the midaxillary line. A 8-cm utility incision is created in the axilla at the 4th intercostal space for upper or middle lobectomy. For lower lobectomy, a 8-cm utility incision is created in the auscultatory triangle at the 5th intercostal space. A 12-mm incision is frequently placed near the utility incision in the 6th intercostal space, particularly when using retraction for improved exposure or for insertion of added instrumentation. We performed the hilar vessel ligation using endoscopic ligation forceps SAITO model (Japan patent no. 4148324). We reported approaches and techniques in our hospital for the patients who underwent VATS lobectomy based on the surgical databases from the Division of Thoracic Surgery at the Kansai Medical University Hirakata Hospital during the period from January 5, 2006 through August 31, 2008.

[Placement of one-way endobronchial valves to treat severe pulmonary emphysema in an 84-year-old]

An 84-year-old man with end-stage emphysema was hospitalised on two occasions because of an episode of severe COPD exacerbation, each time successfully treated in a classical pharmacological manner. Further analysis of a high-resolution CT chest scan revealed very pronounced destruction of the lung parenchyma in the left lower lobe. Moreover, the degree of destruction in the left lung was of a highly heterogeneous nature and fissure analysis revealed a complete left major fissure. After carefully weighing up the costs against the benefits, two one-way valves of different sizes were implanted in the orifices of the left lower lobe using video bronchoscopy. This intervention had a very satisfactory outcome with positive changes in the lung function parameters, imaging studies and quality of life. The inevitable placement in a nursing home could consequently be postponed and, at follow-up one year later, no exacerbation or pneumonia had developed since the intervention.

Robot-assisted thoracoscopic lung resection aimed at solo surgery for primary lung cancer

The surgical robotic system has been advanced as a tool that enables surgeons to perform precision operations of high quality. Many reports have been presented in cardiovascular surgery using the robotic system, but its use is uncommon in general thoracic surgery. We describe our two experiences with single-surgeon video-assisted thoracoscopic surgery lobectomy for primary lung cancer using a remote-controlled robot, named Naviot, to manipulate an endoscope. We believe that Naviot might be one of the robotic devices whose use could lead to solo surgery, even for complicated thoracoscopic procedures such as anatomical pulmonary resections with lymph node dissection.

[Selective lobar blockade using an arndt endobronchial blocker in 2 patients with respiratory compromise who underwent lung resection]

Selective lobar blockade is an alternative to one-lung ventilation in thoracic surgery. We present 2 cases of lung resection with severe respiratory compromise. The first patient had previously undergone a left lower lobectomy and 2 atypical resections in the left and right upper lobes and was scheduled for a right lower lobectomy. The second patient presented chronic obstructive pulmonary disease with forced vital capacity of 1200 mL (26% of predicted value) and forced expiratory volume in 1 second of 820 mL (25% of predicted value) and was scheduled for an atypical resection of the left upper lobe with pleural abrasion. Selective lobar blockade was achieved in both cases using an Arndt endobronchial blocker. Ventilation during the operation was sufficient. Surgery was uneventful in both cases and lobar collapse was satisfactory.

[Thoracoscopic anatomical lung resection in children]

There are only few pediatric surgical centers across the world with expertise for minimally invasive anatomical lung resections in children. Between September 2003 and September 2005, 67 children underwent thoracoscopic surgery at the Department of Pediatric Surgery, University Hospital of Tuebingen, Germany. In 19 of these cases a lung resection was carried out, 8 of them had an anatomical lung resection. All patients underwent general anesthesia without selective intubation for the procedure. Intrathoracic pressure with insufflation of carbon dioxide of 1.5 l / min was held at 3-5 mmHg. Two 5 mm ports for video and instruments and one 12 mm port for a stapling device were used. Resected lung specimens were removed from the thorax through an additional 2-3 cm long incision. A bronchoscopy was carried out during surgery in all patients. Median age at operation was 5.6 years (range 3 months-20 years). Median operation time was 150 minutes (range 94-250 min). Conversion to open surgery was performed in 3 cases. This was due to bleeding in one child, due to a stiff lung in another patient with cystic fibrosis and due to a vascular and bronchial malformation in a third child suffering from middle lobe syndrome. There were no postoperative complications. Our preliminary results show, that thoracoscopic lung resections in children can be performed without major complications and excellent cosmetic results. For the necessity of a conversion to open surgery possible reasons may be insufficient intrathoracic overview as well as congenital anomalies of the vascular and / or the bronchial tract. Co-morbidities such as rib-fusion, deformities of the thorax or scoliosis can be avoided using thoracoscopic procedures.

Design of the Endobronchial Valve for Emphysema Palliation Trial (VENT): a non-surgical method of lung volume reduction

Background

Lung volume reduction surgery is effective at improving lung function, quality of life, and mortality in carefully selected individuals with advanced emphysema. Recently, less invasive bronchoscopic approaches have been designed to utilize these principles while avoiding the associated perioperative risks. The Endobronchial Valve for Emphysema PalliatioN Trial (VENT) posits that occlusion of a single pulmonary lobe through bronchoscopically placed Zephyr^® endobronchial valves will effect significant improvements in lung function and exercise tolerance with an acceptable risk profile in advanced emphysema.

Methods

The trial design posted on Clinical trials.gov, on August 10, 2005 proposed an enrollment of 270 subjects. Inclusion criteria included: diagnosis of emphysema with forced expiratory volume in one second (FEV₁) < 45% of predicted, hyperinflation (total lung capacity measured by body plethysmography > 100%; residual volume > 150% predicted), and heterogeneous emphysema defined using a quantitative chest computed tomography algorithm. Following standardized pulmonary rehabilitation, patients were randomized 2:1 to receive unilateral lobar placement of endobronchial valves plus optimal medical management or optimal medical management alone. The co-primary endpoint was the mean percent change in FEV₁ and six minute walk distance at 180 days. Secondary end-points included mean percent change in St. George's Respiratory Questionnaire score and the mean absolute changes in the maximal work load measured by cycle ergometry, dyspnea (mMRC) score, and total oxygen use per day. Per patient response rates in clinically significant improvement/maintenance of FEV₁ and six minute walk distance and technical success rates of valve placement were recorded. Apriori response predictors based on quantitative CT and lung physiology were defined.

Conclusion

If endobronchial valves improve FEV₁ and health status with an acceptable safety profile in advanced emphysema, they would offer a novel intervention for this progressive and debilitating disease.

Trial Registration

ClinicalTrials.gov: NCT00129584

Convenient and improved method to distinguish the intersegmental plane in pulmonary segmentectomy using a butterfly needle

In the traditional method of segmentectomy, the plane between segments where removal is to occur is demarcated by inflating the normal lung, while keeping the segment to be removed airless. Our method, the opposite of convention, involves inflating only the involved segment by instilling oxygen through a butterfly needle into the bronchus subtending the segment. This saves time and therefore benefits the patient.

Role of Sublobar Resection (Segmentectomy and Wedge Resection) in the Surgical Management of Non–Small Cell Lung Cancer

Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. This anatomic detail makes segmentectomy significantly more challenging than lobectomy. Several principles must be applied when performing segmental lung resection: (1) the surgeon should avoid dissection in a poorly developed fissure, (2) use the transected bronchus as the base of the segmental resection during the division of the lung parenchymal in the intersegmental plane, (3) consider the use of endostapler division of the pulmonary parenchyma to reduce the air leak complications related to "finger fracture" dissection of the intersegmental plane, and (4) consider the use of adjuvant iodine 125 brachytherapy as a means of reducing local recurrence following sublobar resection. Increasing evidence supports the use of anatomic segmentectomy in the treatment of primary lung cancer for appropriately selected patients. This resection approach seems most appropriate in the management of the small (<2 cm in diameter) peripheral stage I NSCLC in which a generous margin of resection can be obtained. Accurate intraoperative nodal staging is important to estimate the relative use of these approaches compared with more aggressive resection and to determine the need for adjuvant systemic therapy if metastatic lymphadenopathy is identified. Future investigations comparing the results of sublobar resection with lobectomy will more clearly define the role of segmentectomy among good-risk patients with clinical stage I NSCLC. At the present time, it seems that sublobar resection is an appropriate therapy for the management of stage I NSCLC identified in the elderly patient, those individuals with significant cardiopulmonary dysfunction, and for the management of peripheral solitary metastatic disease to the lung. Because the primary disadvantage of sublobar resection is that of local recurrence, intraoperative adjuvant iodine 125 brachytherapy may be considered to minimize this local recurrence risk.

Use of Endobronchial Valves for Native Lung Hyperinflation Associated With Respiratory Failure in a Single-Lung Transplant Recipient for Emphysema

Emphysema is a common indication for adult pulmonary transplantation. Double-lung transplantation is increasingly the preferred approach because severe posttransplant native lung hyperinflation (NLH) following single-lung transplantation may compromise allograft lung function. We describe successful emergency use of bronchoscopic lung volume reduction using endobronchial valves (EBVs) [Zephyr; Emphasys Medical; Redwood, CA] in a single-lung transplant recipient who was critically ill with ventilator dependence from complications of NLH and at excessive risk for lung volume reduction surgery or pneumonectomy. Following placement of 17 valves in all segments of the native lung, atelectasis of the native lung was accompanied by volume expansion of the allograft. Immediately following valve placement, peak airway pressure decreased and alveolar ventilation increased. The patient was subsequently weaned from mechanical ventilation. This report suggests the need for clinical trials to evaluate the effectiveness of EBVs in single-lung transplant recipients with less critical functional impairment associated with NLH.

[Usefulness of ultrasonically activated scalpel for pulmonary resection in video-assisted thoracoscopic surgery]

We evaluated the reliability and efficacy of the ultrasonically activated scalpel (Harmonic Scalpel) for pulmonary resection in video-assisted thoracoscopic surgery (VATS). Fifty-six cases of primary or metastatic lung cancer with history of lobectomy or segmentectomy from July 2003 to June 2006 were investigated. The ultrasonically activated scalpel was used to separate aborted lobulation and segment in the surgery. The outcome of the operation using the ultrasonically activated scalpel revealed the mean operation time of 224.5 minutes and mean blood loss volume of 116.7 ml. The chest drainage catheter was removed at the postoperative day 3.4 and hospitalization lasted 10.4 days on average. By means of statistical analysis, no significant differences were noted when compared with the cases using surgical stapler to separate the lobules or segments of the lungs. Histopathological results showed destruction of alveolar structures and denaturation of cells at the cut surface of the resected lung through the use of the ultrasonically activated scalpel. This method resulted in good lung expansion and preservation of the residual lung volume. Furthermore, it prevented postoperative air leakage by appropriate treatment to the cut surfaces of the residual lung. Indeed, the method appears to be useful in the separation of lung tissues in severe aborted lobulation and segmentectomy by VATS.

Alternate suction reduces prolonged air leak after pulmonary lobectomy: a randomized comparison versus water seal

BACKGROUND

The objective of the present study was to compare in a prospective randomized fashion two different management schemes for chest tubes after lobectomy: water seal versus alternate suction (suction overnight and water seal during the day).

METHODS

Ninety-four patients with air leak on the morning of the first postoperative day were randomly assigned to two groups: group 1 (water seal alone), 47 patients; or group 2 (alternate suction), 47 patients. The groups were then compared in terms of preoperative, operative, and postoperative variables.

RESULTS

Alternate suction patients showed a reduced incidence of air leak longer than 4 days (p = 0.04) and longer than 7 days (p = 0.02), a shorter duration of chest tubes in place (p = 0.002), and a shorter postoperative hospital stay (p = 0.004).

CONCLUSIONS

Alternate suction was superior to water seal alone in reducing the incidence of prolonged air leak and postoperative hospital stay after lobectomy. As suction was applied only overnight, this modality has the same advantage of water seal in terms of early mobilization of patients.

Pulmonary artery reconstruction by a custom-made heterologous pericardial conduit in the treatment of lung cancer

Lung cancer may involve the pulmonary artery (PA) either by direct extension of the primary tumor or by invasion of the hilar lymph nodes. In these instances, a radical resection is usually a pneumonectomy despite distal functioning lung tissue. To spare the lung parenchyma, angioplastic procedures requiring removal of a portion of the arterial wall or a circumferential resection with arterial reconstruction have been used. Several techniques of pulmonary arterioplasty have been explored suggesting that the incidence of postoperative complications is acceptably low and long-term local control can be achieved. Over a period of 7 years, 84 angioplastic procedures (alone or associated with bronchoplasty) were performed at our institution. Partial PA resection was performed in 80 (95.2%) patients. Reconstruction was performed by running suture in 63 (75%) patients and using a pericardial patch in 17 (20.2%) cases (16 autologous and 1 heterologous). A complete PA resection and reconstruction was performed in four (4.8%) patients by a polytetrafluoroethylene (PTFE) prosthesis (n=2) and by a custom-made bovine pericardial conduit (n=2). The latter are the topic of this report.

A new bioabsorbable sleeve for lung staple-line reinforcement (FOREseal): report of a three-center phase II clinical trial

OBJECTIVE

To investigate on the feasibility, safety, and effectiveness of a new bioabsorbable material for lung staple-line reinforcement.

METHODS

This prospective open trial included 66 patients (mean age of 56+/-17 years) who underwent various types of lung resection using staplers with knitted calcium alginate sleeves for buttressing (FOREseal, Laboratoires Brothier, Nanterre, France) at three academic centers: 29 lobectomies, 22 emphysema surgeries, 15 wedge resections or lung biopsies. Intraoperative air leakage was assessed at a mean respiratory peak pressure of 30 cmH2O, and rated as grade 1, 2, or 3. Persistent air leakage in the postoperative course, as well as any relevant event, was assessed daily. The follow-up period was of 6 months.

RESULTS

No technical problem linked to the device occurred. Hemostasis of the cutting edges was completed in all patients. Fifty-six percent of the patients had no intraoperative air leak and 27.3% had grade 1 leaks. Mean postoperative air leaks and thoracic drainage times were 1.9+/-2.3 days and 6+/-5.3 days, respectively. In-hospital mortality was nil. There was no empyema. Mean hospital stay was 9.1+/-6.6 days. At follow-up, one patient underwent lung transplantation, and pathology of the explanted specimen showed the absence of device-related foreign-body inflammation. One patient complained from metalloptysis, and another one, with a metastatic invasive aspergillosis, developed an infectious recurrence that required reoperation.

CONCLUSIONS

FOREseal is an ergonomic, safe, and promising new material instead of nonabsorbable materials and xenomaterials for staple-line reinforcement. A randomized comparative study is now in progress.

Detecting the limits of bronchial closure methods in an animal model

BACKGROUND

Bronchopleural fistula is a serious complication of major lung resections that may lead to mortality. An experimental animal model was designed to find out the safest bronchial closure method by comparing leakage rates under pressure.

METHODS

The tracheobronchial trees of 50 freshly dead sheep were prepared for either manual closure or closure with a stapler. After left pneumonectomy, the specimens were divided into five groups (n = 10); 3/0 Premilene suture was used with two "u" sutures + interrupted sutures in Group I; in Group II, 3/0 Premilene sutures with continuous horizontal mattress + over-over continuous sutures were used. In Group III and IV the same techniques were used with 3/0 Vicryl. A stapler was used in Group V. Specimens were intubated with an endotracheal tube, connected to a sphygmomanometer, and subsequently positioned under water. The pressure level at which we detected air bubbles indicated the limits of the technique.

RESULTS

The median leakage pressure resistance was significantly lower in Group III (135 mm Hg) ( P = 0.001). The best results were achieved by using the continuous horizontal mattress + over-over continuous suture technique. No statistical significance difference was found between the stapler group, Groups I, II, and IV in terms of median leakage pressures.

CONCLUSIONS

This trial suggests that manual suture closure using an appropriate technique and monofilament materials is as safe as the stapler.

A Completely Thoracoscopic Lobectomy/Segmentectomy for Primary Lung Cancer - Technique, Feasibility, and Advantages

INTRODUCTION

A completely thoracoscopic lobectomy/segmentectomy for primary lung cancer was designed to maximize the benefits of this type of minimally invasive surgery. The technique, feasibility, and advantages of this surgical modality over the conventional procedure were investigated.

MATERIALS AND METHODS

Between January 2003 and December 2004, 38 patients underwent a lobectomy (n = 30) or segmentectomy (n = 8) for clinical stage IA primary lung cancer. A resection using a standard thoracotomy (Thoracotomy Group) was performed in 19 patients, and a completely thoracoscopic resection was performed in 10 cases (CTR Group). Conventional video-assisted thoracic surgery with a mini-thoracotomy was performed in 9 cases.

RESULTS

All CTR lobectomies or segmentectomies were carried out safely without any major complications. The number of resected mediastinal lymph nodes was similar in both groups. There was a tendency for the hospital stay to be somewhat shorter in the CTR Group. With respect to postoperative pain as evaluated by a visual analogue scale (VAS), the CTR Group showed a significantly lower level of pain in comparison to the Thoracotomy Group ( P = 0.024 on day 2).

CONCLUSIONS

We concluded that a complete thoracoscopic lung resection is a safe and technically feasible surgical procedure which enables us to make thoracoscopic lung resections less invasive.

Combined off-pump coronary surgery and left lung resection through midline sternotomy with a Medtronic Starfish 2 Heart Positioner

Concomitant lung malignancy and coronary artery disease is uncommon. When the left lung is involved, the approach is considered to be staged or through left thoracotomy. We present a patient who was operated on for left pneumonectomy and off-pump coronary surgery through a midline sternotomy with the use of a Medtronic Starfish 2 Heart Positioner.

Bronchoscopic Lung Volume Reduction for End-Stage Emphysema

OBJECTIVES

To report the first multicenter experience on the treatment of end-stage emphysema using an endobronchial valve (EBV) [Emphasys EBV; Emphasys Medical; Redwood City, CA].

DESIGN

Retrospective analysis from prospective multicenter registry.

PATIENTS AND INTERVENTIONS

This is a study of the use of EBVs in the treatment of end-stage emphysema at nine centers in seven countries. Ninety-eight patients with mean FEV(1) of 0.9 +/- 0.3 L (30.1 +/- 10.7% of predicted) [+/- SD] and residual volume (RV) of 5.1 +/- 1.3 L (244.3 +/- 0.3% of predicted) were treated over a period of 20 months. Spirometry, plethysmography, and diffusing capacity of the lung for carbon monoxide (Dlco) and exercise tolerance testing were performed at 30 days and 90 days after the procedure.

RESULTS

RV decreased by 4.9 +/- 17.4% (p = 0.025), FEV(1) increased by 10.7 +/- 26.2% (p = 0.007), FVC increased by 9.0 +/- 23.9% (p = 0.024), and 6-min walk distance increased by 23.0 + 55.3% (p = 0.001). There was a trend toward improvement in Dlco, but this did not reach statistical significance (17.2 +/- 52.0%, p = 0.063). Patients treated unilaterally showed a trend toward greater improvement than those treated bilaterally. A similar trend toward improvement was observed in patients who had one entire lobe treated compared to those with just one or two bronchopulmonary segments treated. Eight patients (8.2%) had serious complications in the first 90 days, including one death (1.0%).

CONCLUSION

This multicenter analysis confirms that improvement in pulmonary function and exercise tolerance can be achieved in emphysematous patients using EBVs. Future efforts should be directed to determining how to select those patients who would benefit most from this procedure and the best endobronchial treatment strategy.

Bronchoscopic procedures for emphysema treatment

Emphysema is a debilitating lung disease continuing to be a major source of morbidity and mortality in the developed countries. Medical treatment is the mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation, administration of bronchodilators and, when indicated, steroids and supplemental oxygen. Various surgical procedures have been promoted in the past to relieve dyspnoea and improve quality of life in patients with advanced emphysema; whilst early results were often encouraging, a sustained objective functional improvement was rarely achieved and most of those procedures were progressively abandoned. Despite controversies, LVRS has been shown to be beneficial to selected patients with end-stage emphysema when medical therapy has failed. There is no doubt that LVRS allows a significative functional improvement in a selected group of patients; however, it still carries a substantial morbidity, even if mortality is low at the centres with the larger experience. Patients with a most advanced functional deterioration show a higher surgical mortality and less impressive functional results, suggesting that LVRS should be considered more carefully in these situations. Bronchoscopic alternatives to the surgical approach have been recently proposed and some of them may play an important role in the future; in particular, the airway bypass and bronchoscopic lung volume reduction with one-way valves are certainly one step beyond on their way to clinical application. We hereby report the initial experimental and clinical experience with these new treatment options.

Limited resection trial for pulmonary ground-glass opacity nodules: fifty-case experience

OBJECTIVE

This study was undertaken to determine the recurrence rate after limited resection of small lung carcinoma and to evaluate intraoperative frozen-section examination accuracy for Noguchi classification.

METHODS

Enrollment requirements were as follows: pulmonary nodule 2 cm or smaller, diagnosed or suspected clinical T1 N0 M0 carcinoma in the lung periphery, and ground-glass opacity findings and lack of evident pleural indentations or vascular convergence on high-resolution computed tomographic scan. A wedge or segmental resection specimen, removed with custom stapler cartridges, was immediately reinflated and examined by frozen-section with hematoxylin-eosin and Victoria blue-van Gieson stains. If the tumor was confirmed as Noguchi type A or B with resection margins greater than 1 cm, the patient was closed and followed up on an outpatient basis. End points were 5-year disease-free survival and intraoperative classification accuracy.

RESULTS

From August 1998 through October 2002, a total of 50 patients were enrolled (20 men and 30 women, ages 30-77 years). Tumor sizes ranged from 2 to 21 mm (11 mm average). There were 2 Noguchi type A tumors, 23 Noguchi type B tumors, 15 Noguchi type C tumors, 5 atypical adenomatous hyperplasias, 4 fibroses, and 1 granuloma. Frozen-section accuracy was approximately 98% (39/40). One intraoperative type B diagnosis was revised to type C after postoperative pathologic study. No morbidity, mortality, or recurrence has been seen with a median follow-up of 50 months.

CONCLUSION

Noguchi type A and B tumors may well be in situ carcinomas, and frozen-section examination was highly accurate. Neither local recurrence nor distant metastases have been found to date. Limited resection initial results appear promising.

[Measurement of air leak volume after lung surgery using web-camera]

Persistent air leak from the lung is one of the major complications after lung operations, especially in the latest thoracic surgery, where a shorter hospital stay tends to be necessary. However, air leak volume has been rarely measured clinically because accustomed tools of gas flow meter were types which needed contact measure, and those were unstable in long-term use and high cost. We tried to measure air leak volume as follows: (1) Bubble was made in the water seal part of a drain bag. (2) The movement of bubbles was recorded with a web-camera. (3) The data from the movie was analyzed by Linux computer on-line. We believe this method is clinically applicable as a routine work after lung surgery because of non-contact type of measurements, its stableness in long-term, easiness to be handled, and reasonable in cost.

Innovative approaches to lung volume reduction for emphysema

The 10 years of resurgent interest in lung volume reduction surgery (LVRS) and recent National Emphysema Treatment Trial findings for emphysema have stimulated a range of innovative alternative ideas aimed at improving outcomes and reducing complications associated with current LVRS techniques. Concepts being actively investigated at this time include surgical resection with compression/banding devices, endobronchial blockers, sealants, obstructing devices and valves, and bronchial bypass methods. These novel approaches are reaching the stage of clinical trials at this time. Theory, design issues, methods, potential advantages and limitations, and available results are presented. Extensive research in the near future will help to determine the potential clinical applicability of these new approaches to the treatment of emphysema symptoms.

First experiences with the da Vinci operating robot in thoracic surgery

OBJECTIVES

The da Vinci surgical robotic system was purchased at our institution in June 2001. The aim of this trial was to evaluate the applicability of the da Vinci operation robot for general thoracic procedures.

METHODS

The da Vinci surgical system consists of a console connected to a surgical arm cart, a manipulator unit with two instrument arms and a central arm to guide the endoscope. The surgical instruments are introduced via special ports and attached to the arms of the robot. The surgeon, sitting at the console, triggers highly sensitive motion sensors that transfer the surgeon's movements to the tip of the instruments. The so-called 'EndoWrist technology' offers seven degrees of movement, thus exceeding the capacity of a surgeon's hand in open surgery. We evaluated the role of the robot for several thoracic procedures such as thymectomies, fundoplications, esophageal dissections, resection of mediastinal masses and a pulmonary lobectomy.

RESULTS

A total of 10 thymectomies, 16 fundoplications, 4 esophageal dissections, 5 extirpations of benign mediastinal masses and 1 right lower lobectomy was performed with the robot. One resection of a paravertebral neurogenic tumor had to be converted due to surgical problems. A lesion to a left recurrent laryngeal nerve caused transient hoarseness after the extirpation of an ectopic parathyroid in the aortopulmonary window in one patient. The postoperative courses were uneventful and patients were discharged between postoperative days 3 and 8 (with the exception of patients who underwent dissection for esophageal cancer and the patient with conversion to an open access).

CONCLUSIONS

Advanced general thoracic procedures can be performed safely with the da Vinci robot allowing precise dissection in remote and difficult-to-reach areas. This benefit becomes evident most elegantly in thymectomies, which at our institution have become a routine procedure with the robot. The rigid anatomy of the chest seems to be an ideal condition for robotic surgery. A major limitation for robotic surgery is the lack of more appropriate instruments. This disadvantage becomes most evident in pulmonary lobectomies.

Early results of endoscopic lung volume reduction for emphysema

BACKGROUND

We determined the feasibility, safety, and short-term efficacy of bronchoscopic placement of a one-way endobronchial valve in selected bronchopulmonary segments as an alternative to surgical lung volume reduction.

METHODS

A total of 21 patients with incapacitating emphysema who underwent this procedure were studied. All patients had placement of the endobronchial valves into the most emphysematous lung segments. We recorded any major complications or deaths attributed to the procedure and analyzed (1) improvements in the spirometric and functional parameters and quality of life and (2) the radiologic changes compared with the baseline data at 30 and 90 days.

RESULTS

A total of 20 patients had complete follow-up data. There was no mortality in the group studied. The forced expiratory volume at 1 second, forced expiratory volume at 1 second (percentage of predicted), forced vital capacity, and forced vital capacity (percentage of predicted) all improved significantly at 90 days (0.73 +/- 0.26 L vs 0.92 +/- 0.34 L [P =.009]; 33.3% +/- 11.9% vs 42.2% +/- 15.0% [P =.006]; 1.94 +/- 0.62 L vs 2.25 +/- 0.61 L [P =.015]; and 63.3% +/- 17.6% vs 73.9% +/- 17.1% [P =.012], respectively). The 6-minute walking distance improved at 30 and 90 days (251.6 +/- 100.2 m vs 306.3 +/- 112.3 m and 322.3 +/- 129.7 m; P =.012 and P =.003). The results of the 36-Item Short-Form Health Survey and the St George Respiratory Questionnaire showed significant improvements at 90 days. The Medical Research Council dyspnea grade also improved significantly at 30 and at 90 days (P =.006 and P =.003, respectively).

CONCLUSIONS

Endobronchial valve placement is a safe procedure, with significant short-term improvements in functional status, quality of life, and relief of dyspnea in selected patients with emphysema. A larger study with long-term follow-up is therefore warranted.

A new tissue-sealing technique using the Ligasure system for nonanatomical pulmonary resection: preliminary results of sutureless and stapleless thoracoscopic surgery

PURPOSE

We present our initial evaluation of a new surgical technique of lung tissue sealing for nonanatomical pulmonary resection composed of sutureless and stapleless thoracoscopic surgery.

DESCRIPTION

Twelve patients who required therapeutic thoracoscopic pulmonary resection from April 2001 to April 2002 were recruited for this study. Resection of lung parenchyma was performed with an ultrasound-driven scalpel, and the cut end was sealed using LigaSure, a new bipolar system. Measurement of the cut surface after resection during the surgery and assessment of LigaSure sealing strength was performed.

EVALUATION

There were no deaths or major intraoperative complications. The mean operation time was 65 minutes, and mean hemorrhage volume was 46 mL. Average chest drain duration was 3 days, and average hospital stay was 6 days. One patient with a giant bulla and cut surface diameter of 50 mm experienced persistent air leak for 1 week. Late complications did not occur over the 8-month follow-up period.

CONCLUSIONS

Video-assisted thoracoscopic surgery pulmonary resection using LigaSure instead of staplers appears technically feasible and easy, and produces satisfactory preliminary results. Although further studies are required to confirm the sealing strength and reliability of LigaSure, this technique should be considered for use in nonanatomical pulmonary resections.

Lung Volume Reduction Surgery in Canine Model of Predominantly Upper Lobe Emphysema

OBJECTIVE

Lung volume reduction surgery has been shown to be an effective treatment for selected patients with advanced emphysema. Nevertheless, prolonged air leaks are a significant complication that limits the utility of this procedure. This study evaluated the safety and effectiveness of a novel surgical system designed to minimize this complication.

METHODS

In 14 dogs, severe upper lobe emphysema was produced by repeated bronchial instillations of papain administered over an approximate 6-month interval. Pulmonary function testing that included lung volumes and flows was performed at baseline, after emphysema, and at 1 month and 6 months after resection in the surgical group, while at comparable intervals in the nonsurgical group. Seven animals were randomly assigned to a surgical group to test a vacuum-assisted surgical system (VALR Surgical System; Spiration; Redmond, WA) that deploys a compression silicone sleeve over portions of the diseased tissue. The other seven dogs comprised the nonsurgical group.

RESULTS

In both groups, emphysema increased total lung capacity (TLC) approximately 125% as compared to baseline. In the surgical group, no air leaks were observed after resection, and TLC significantly decreased at the 1-month and 6-month periods as compared with postemphysema measurements. At necropsy, histologic examination revealed fibrosis of the compressed lung contained within the sleeve and fibrotic encapsulation of the device. Two animals had evidence of localized infection.

CONCLUSION

We successfully created a model of predominantly upper lobe emphysema. The vacuum-assisted surgical system provided safe and effective lung reduction without air leak complications and with sustained improvement in pulmonary function over 6 months.

Methodological Aspects of Bronchoscopic Lung Volume Reduction with a Proprietary System

Bronchoscopic lung volume reduction (BLVR) is emerging as a new technique to palliate symptoms in patients with severe emphysema. Several devices and techniques are being developed to occlude airways resulting in collapse and reduced lung volume. Here we present in detail the methodological aspects of one such interventional bronchoscopic approach.

Novel surgical system for reducing lung tissue and preventing air leaks

PURPOSE

This study assessed the feasibility of using the VALR surgical system (Spiration Inc, Redmond, WA), limited by federal law to investigational use, for capturing and reducing a selected portion of affected lobes in patients undergoing lobectomy.

DESCRIPTION

The tested system consists of a hand-held vacuum-regulated introducer loaded with a flexible, silicone sleeve. Targeted tissue is drawn into the introducer and the silicone sleeve is deployed and sutured in place. The end of the proximal sleeve includes a compression band for applying uniform radial pressure, suture ports, and silicone lugs lining the inner lumen for reinforcing sleeve position.

EVALUATION

The system was effective in capturing 25% to 30% tissue of each lobe tested. Mean intraoperative test time was 8.5 minutes. The compression sleeve did not slip or dislodge after suturing, and no tissue damage or leaks were observed.

CONCLUSIONS

It was feasible using vacuum to draw and isolate a portion of pulmonary tissue within a silicone sleeve. The system was intuitive to apply, easy to use, and produced effective reduction and sealing of tissue.

A new technological approach to nonanatomical pulmonary resection: saline enhanced thermal sealing

BACKGROUND

This is the first clinical report on the feasibility study of two new devices (monopolar Floating Ball and bipolar Sealing Forceps; TissueLink Medical Inc, Dover NH) that incorporated the novel technology of saline enhanced thermal sealing.

METHODS

From December 2000 to December 2001, 25 patients (mean age, 54.8 years) with peripheral lung nodules planned for either diagnostic or therapeutic wedge resection were recruited for the study. When the nodule lay deep to a flat lung surface, video-assisted thoracic surgical resection using the modified Perelman technique with the Floating Ball (TissueLink Medical Inc) was preferred. In other patients, the Sealing Forceps (TissueLink Medical Inc) were used for video-assisted thoracic surgical wedge resection.

RESULTS

There were no mortality or major intraoperative complications. The Floating Ball was used exclusively in 11 patients; the Sealing Forceps were used in 9 patients; and a combination of the two devices was used in 5 patients. The mean operation time was 70.3 minutes. Average chest drain duration was 3.9 days, and postoperative hospital stay was 5.2 days. There were 2 patients with persistent air leak more than 1 week, one who resolved spontaneously, and the other who required reoperation for control. One patient had pulmonary embolism after a technically uneventful procedure. There have been no late complications after an average follow-up of 10 months.

CONCLUSIONS

The devices appear to be technically safe. The Floating Ball has definite advantages over the conventional diathermy and can be adapted to the Perelman procedure using the video-assisted thoracic surgical approach. The Sealing Forceps hold promise to reduce overall consumable costs compared with conventional staplers. These devices should complement the surgeon's existing armamentarium. Comparative studies with conventional instruments are warranted to further define the role of these new devices in thoracic operations.

Lobe-sparing resection of multiple pulmonary metastases with a new 1318-nm Nd:YAG laser--first 100 patients

BACKGROUND

A new 1318-nm Nd:YAG laser has been developed to utilize the second wavelength (1318 nm; 40 watt) to more precisely cut, coagulate, and seal lung tissue adjacent to pulmonary nodules. This laser allows a precise intraparenchymal nodulectomy with a 5-mm rim of tissue destruction and subsequent lung parenchymal reapproximation to avoid lobar distortion. Resection of multiple, bilateral, and recurrent tumors in the lung is facilitated by this laser technique.

METHODS

In 100 consecutive patients (53 men, mean age 60 years; 47 women, mean age 61 years) with various primaries (most commonly renal and colorectal), 155 laser resections were performed via anterolateral thoracotomy (staged 3 to 4 weeks, if bilateral) using a new 1318-nm Nd:YAG laser. All palpable and visible masses were removed with 2 to 3-mm visible tumor margins (plus a 5-mm rim of residual lung necrosis secondary to laser energy dispersal) if the tumor or residual lung ratio was judged favorable. No stapling devices or bioadhesives were used.

RESULTS

Six hundred thirty-two metastases (6.3 per patient, range 1 to 124) were resected. Despite 41% centrally located metastases, tumor resections were possible in 95% of patients with only a 5% lobectomy rate. Of the 100 patients, 67 were considered "curative" with complete metastasectomy by inspection and palpation, and 23 were judged incomplete from too extensive tumor or residual lung, miliary lung spread, or pleural studding. There were no associated mortalities and two complications, including bleeding (1) and a prolonged airleak (1), both treated conservatively. Follow-up was complete in all patients for a median of 26.5 months with clinic visits and chest computed tomographic scan every 3 to 6 months. Nine recurrences were detected and underwent reoperation. Overall survival in the completely resected "curative" group was 85% at 1 year, 71% at 2 years, 69% at 3 years, 57% at 4 years, and 32% at 5 years; in the completely resected "palliative" group, they were 70% at 1 year, 36% at 2 years, 12% at 3 years, and 0 at 4 years; in the incomplete group, they were 56% at 1 year, 30% at 2 years, and 0 at 3 years.

CONCLUSIONS

The new 1318-nm Nd:YAG laser is parenchyma-sparing, improves complete resection rates, and potentially improves survival with fewer required lobectomies.

VATS major pulmonary resection revisited--controversies, techniques, and results

The application of video-assisted thoracoscopic surgery (VATS) in major pulmonary resections has remained infrequent, despite earlier demonstration of its technical feasibility. The early postoperative benefits of this approach to patients are now well documented. The intermediate to long-term clinical results of VATS major resections for primary cancer are now available and appear extremely encouraging. There are few, detailed descriptions of this technique in the literature. This article reviews the current status of VATS major resection with emphasis on its controversies, techniques, and results.

Operative technique for safe pulmonary lobectomy in Sprague-Dawley rats

To perform safe and effective animal surgery, it is essential to follow a well- disciplined approach. We recently have embarked on a variety of wound-healing studies that involve multiple operative techniques including thoracotomy with lobectomy. Such procedures require specific attention to effective anesthesia and ventilation as well as a structured and safe approach to the actual procedure. We have developed operative techniques for thoracotomy and pulmonary lobectomy that limit animal morbidity and mortality. Using general anesthesia, we safely and effectively completed right thoracotomy and pulmonary lobectomy in 51 of the 54 (>94%) of the Sprague-Dawley rats that were our subjects. We effectively ventilated the animals with inhalation anesthesia, avoiding the need for endotracheal intubation. The three mortalities occurred during early experiments and were attributable to easily identified technical errors. Our animals did not experience postoperative respiratory complications. Postoperative recovery was excellent, and no appreciable postoperative morbidity was encountered.

Effects of a novel implantable elastomer device for lung volume reduction surgery in a rabbit model of elastase-induced emphysema

OBJECTIVES

There is intense interest in lung volume reduction surgery (LVRS) for treatment of severe symptomatic emphysema. LVRS results in objective and subjective improvement in lung function in selected patients. However, LVRS is complicated by substantial morbidity, including prolonged pulmonary air leak associated with resection of emphysematous lung tissue. In this study, we investigated the use of a novel implanted silicone elastomer device that reduces lung volume without surgical resection, in a previously reported emphysematous animal model. The purpose of this investigation was to determine the applicability, physiologic effects, complications, and air-leak results of this lung volume reducer (LVR) approach.

DESIGN

Controlled, randomized, prospective animal study. Emphysema was induced in 20 New Zealand white rabbits with three nebulizations of 10,000 U of porcine elastase. After 6 weeks, the animals were randomized to control sham surgery (n = 10) vs implanted silicone elastomer LVR (n = 10) treatment groups. Lung function, including helium-dilution lung volumes, static respiratory system compliance curves, and diffusion capacity of the lung for carbon monoxide (DLCO), was measured at baseline, following emphysema induction (week 6), and when the animals were killed (1 week after LVR or sham surgery). Histologic evaluation was performed in all lung specimens after fixation.

RESULTS

Moderate emphysema developed after elastase nebulization, assessed by lung function and postmortem histology. Functional residual capacity (FRC) and an upward shift of lung compliance curves was observed with development of emphysema at 6 weeks (p < 0.05). Following LVR, FRC decreased (p = 0.005) and compliance curves shifted back downward (p = 0.002), without reduction in DLCO. There was no change in control sham animals. DLCO did not change in either group.

CONCLUSIONS

In this short-term, randomized, controlled animal model study, the implantable LVR approach produced safe and effective lung volume reduction without tissue resection in the treated animals. The implant procedure produced minimal morbidity, no mortality, and no observed air-leak complications in the treated animals. Limitations include the short-term follow-up and moderate degree of emphysema in this animal model. Further research is required to assess long-term effects and complications of this method for lung volume reduction.

Metalloptysis: a late complication of lung volume reduction surgery

We describe three cases where patients expectorated titanium staples many months after lung volume reduction surgery (LVRS). The possible mechanisms and technical implications of this rare complication are discussed.

Asymptomatic expectoration of surgical staples complicating lung volume reduction surgery

Lung volume reduction surgery (LVRS) has recently been introduced as a palliative treatment for patients with severe emphysema. The most common postoperative complication is persistent air leak requiring prolonged tube thoracostomy. We describe a unique case of a patient with severe emphysema who underwent LVRS and presented, about a year later, with the repeated expectoration of surgical staples.

Buttressing the staple line in lung volume reduction surgery: a randomized three-center study

BACKGROUND

The intention of buttressing the staple line in lung volume reduction surgery is to reduce air leaks and to shorten the hospital stay. A randomized three-center study was carried out to test this hypothesis.

METHODS

Sixty-five patients with a mean age of 59.2 +/- 1.2 years underwent bilateral lung volume reduction surgery by video-assisted thoracoscopy using endoscopic staplers (ET 45B; Ethicon Endo-Surgery, Cincinnati, OH) either without or with bovine pericardium for buttressing (Peri-Strips Dry; Bio-Vascular, Inc, Saint Paul, MN). There were no differences between the control and treatment groups in lung function, degree of dyspnea, and arterial blood gases before and 3 months after LVRS.

RESULTS

Seven patients (3 in the treatment group) needed a reoperation because of persistent air leak. The median duration of air leaks was shorter in the treatment group (0.0 day [range, 0 to 28 days versus 4 days [range, 0 to 27 days); p < 0.001), confirmed by a shorter median drainage time in this group (5 days [range, 1 to 35 days] versus 7.5 days [range, 2 to 29 days); p = 0.045). Hospital stay was comparable between the two groups (9.5 days [range, 6 to 44 days] versus 12.0 days [range, 5 to 46 days]; p = 0.14).

CONCLUSIONS

Buttressing the staple line significantly shortens the duration of air leaks and the drainage time. As hospital stay did not differ significantly between the two groups, cost-effectiveness may depend on the local situation.

Bilateral open treatment of spontaneous pneumothorax: a new access

A new technique for bilateral apical bullectomy and pleurectomy via axillary minithoracotomy and transmediastinal access to the contralateral side, was used in 13 patients with bilateral apical blebs and/or pneumothorax. The contralateral space is reached at the posterior superior mediastinum, passing between the first thoracic vertebral bodies (T1-T4) and the oesophagus. The contralateral lung apex is then pulled into the thoracotomy side and apical bullectomy carried out by linear stapler. The obvious advantages of avoiding a second thoracotomy while providing complete solution to the clinical problem are particularly important in young patients with spontaneous pneumothorax caused by bilateral apical blebs.

Evaluation of ultracision in lung metastatic surgery

BACKGROUND

There are very few studies on the histological outcome of lung metastatic surgery using the Ultracision particularly in deeper areas of the lung.

METHODS

In a prospective study, we resected 24 lung metastases from 18 patients using the Ultrasonic scalpel (Ethicon Endo-Surgery, Norderstedt, Germany). We analyzed the risk of bleeding and air leakage as well as the histopathological features of the resection area.

RESULTS

There was no intraoperative bleeding and, in 72%, no intraoperative air leakage. The resection surface was closed with a suture. In 8 cases, the metastases were located deeply, near the hilus of the lobe which did not necessitate a lobectomy. Histologically, occluded blood vessels as well as occluded small bronchioli under 0.1 cm were observed. There was no evidence of deep tissue destruction. No postoperative complications occurred.

CONCLUSIONS

Ultracision in metastatic lung surgery is an appropriate method of treatment with minimum risk of bleeding or air leakage. This procedural approach allows for adequate resection of lung metastases while sparing a generous amount of healthy lung tissue.

Extended left pneumonectomy combined with off-pump coronary revascularization (CABG)

Here, we will report on a 63-year-old patient with a centrally located squamous cell carcinoma of the left lung with complete atelectasis and tumor infiltration into mediastinal pleura and fat. A known coronary two-vessel disease, which became highly symptomatic during the operation made a change of the planned surgical strategy necessary.