A standard muscle-sparing utility thoracotomy for VATS procedures

BACKGROUND

Improvements in surgical equipment have rendered video-assisted thoracic surgery (VATS) an effective device for thoracic surgeons and nowadays several intrathoracic diseases can benefit from this approach. This development has expanded potential use and recently the technical feasibility of major lung resections by VATS has been demonstrated. The authors present their experience with a standard muscle-sparing utility thoracotomy (UT) utilized for all VATS procedures, including major lung resections.

METHODS

From November 1996 to October 1997, 30 patients were operated on. There were 22 males and 8 females (medium age 58 years; range 24-78). There were 13 anatomical lung resections (i.e.: 11 lobectomies, 1 left pneumonectomy, 1 segmental resection), 8 wedge resections, 3 lung biopsies, 2 debridements of pleural empyema, 2 mediastinal nodes biopsies, 1 esophageal resection for leiomyoma, 1 excision of benign mediastinal cyst.

RESULTS

No mortality or major morbidity were recorded, as well as no rib fractures due to the rib spreader. Two patients suffered from prolonged air-leaks after respectively left upper lobectomy and lung biopsy and required prolonged chest drainage. Concerning anatomic major lung resections the medium hospital stay was 7.9 days and medium chest tube time was 5.6 days. The utility thoracotomy through the auscultatory triangle proved to be a safe approach and confirmed the technical feasibility of various type of surgical procedures with results comparable to standard open thoracotomy. Our data shows that VATS approach did not seriously affect the duration of hospital stay, chest tube time, the overall morbidity or lung function.

CONCLUSIONS

As the real benefit of this approach remains controversial, the majority of the studies comparing the VATS approach to conventional muscle-sparing thoracotomy neither nor prospective nor randomized, and several parameters are difficult to evaluate in the literature further study are mandatory.

Morbidity and validity of the hemiclamshell approach for thoracic surgery

OBJECTIVE

This is a prospective study to evaluate the indications and outcome of the hemiclamshell incision (longitudinal partial sternotomy combined with an antero-lateral thoracotomy) as used for a consecutive series of patients requiring surgery for various thoracic pathologies not ideally approached by postero-lateral thoracotomy, sternotomy or thoracoscopy.

METHODS

All patients with a hemiclamshell incision performed between 1994 and 1998 were prospectively analyzed regarding indications, postoperative morbidity and outcome (clinical examination and pulmonary function testing) in order to validate this incision for thoracic surgery.

RESULTS

25 patients (15 men, 10 women) with an age ranging from 16 to 73 years (mean 43 years) underwent a hemiclamshell incision. The indications for the hemiclamshell approach were (1) chest trauma with massive hemorrhage requiring urgent access to the mediastinum and the ipsilateral pleural space (40%), (2) tumors of the anterior cervico-thoracic junction with suspicion of vascular involvement (28%) and (3) lesions involving both one chest cavity and the mediastinum (32%). The 30-day mortality was 8%. One patient suffered a sternal wound infection, mediastinitis and pleural empyema after a gun shot wound, whereas wound healing was uneventful in all other patients. Analgesic requirements for postoperative pain relief were not increased as compared to those following a standard thoracotomy. At 3 months normal sensitivity of the entire chest wall and intact shoulder girdle function was noted in 90% of the patients. Pulmonary function testing showed no restriction due to the hemiclamshell incision.

CONCLUSIONS

The hemiclamshell incision is a useful approach in selected patients and does not cause more morbidity or long-term sequelae than a standard thoracotomy.

Management of a patient with hepatic-thoracic-pelvic and omental hydatid cysts and post-operative bilio-cutaneous fistula: a case report

In humans, most hydatid cysts occur in the liver and 75% of these are single. Our patient was a 31 year-old male. His magnetic resonance imaging (MR) showed one cyst (15 x 20 cm) in the right lobe and three cysts (5 x 6 cm, 8 x 6 cm, and 5 x 5 cm) in the left lobe of the liver, two cysts (4 x 5 cm and 5 x 5 cm) on the greater omentum, and two cysts (15 x 10 and 10 x 10 cm) in the pelvis. The abdomen was entered first by a bilateral subcostal incision and then by a Phennenstiel incision. Partial cystectomy + capitonnage was done on the liver cysts; the cysts on the omentum were excised, and the pelvic cysts were enucleated. The cyst in the right lobe of the liver was in communication with a thoracic cyst. An air leak developed from the thoracic cyst which had underwater drainage and bile drainage from the drain in the cavity of the right lobe cyst. Sphincterotomy was done on the seventh post-operative day by endoscopic retrograde cholangiopancreatography (ERCP). No significant effect on mean bile output from the fistula occurred. Octreotide therapy was initiated, but due to abdominal pain and gas bloating the patient felt and could not tolerate, it was stopped on the fourth day; besides, it had no decreasing effect on bile output during the 4 days. Because air and bile leak continued and he had bile stained sputum, he was operated on on post-operative day 18. By right thoracotomy, the cavity and the leaking branches were closed. By right subcostal incision, cholecystectomy and T-tube drainage of the choledochus were done. On post-operative day 30, he was sent home with the T-tube and the drain in the cavity. After 3 months post-operatively, a second T-tube cholangiography was done, and a narrowing in the distal right hepatic duct and a minimal narrowing in the distal left hepatic duct were exposed. Balloon dilatation was done by way of a T-tube. Bile drainage ceased. There was no collection in the cavity in follow-up CT scanning, so the drain in the cavity, and the drainage catheter in the right hepatic duct were extracted. Evaluation of the biliary ductal system is important in bilio-cutaneous fistulas, and balloon dilatation is very effective in fistulas due to narrowing of the ducts.

Ectopia hepatica extrathoracica nuda associated with amelia and pulmonary agenesis

A neonate with a constellation of unusual congenital deformities associated with pulmonary agenesis is reported.

[Video thoracoscopy and video-assisted thoracic surgery. An analysis of 303 consecutive cases]

OBJECTIVES

To present our experience in video thoracoscopy and video-assisted thoracic surgery from November of 1991 until November of 1997.

PATIENTS AND METHODS

303 endoscopic thoracic surgery procedures (210 males and 93 females with a mean age of 42.2 years) with the following indications: 151 spontaneous pneumothorax, 51 pulmonary biopsies, 50 pulmonary nodules, 15 mediastinal tumors, 13 pleuroparietal tumors, 8 pericardial windows and 15 thoracic sympathectomies.

RESULTS

Mean postoperative stay was of 5.5 days. The thoracotomy conversion was necessary in 32 cases (10.9%). The morbimortality has been: one parietal recidive of a tumor in the way of one of the trocars and one death of a patient to who was accomplished a pulmonary biopsy by diffuse pneumopathy.

CONCLUSIONS

The video thoracoscopy and thoracic surgery are effective and sure technical options for diagnosis and treatment of various thoracic affections.

Is preoperative percutaneous fine-needle aspiration cytology of intrathoracic lesions advisable in resectable patients?

OBJECTIVE

The study addresses the clinical significance of percutaneous fine-needle aspiration (FNA) cytology in patients with intrathoracic lesions.

METHODS

The diagnoses based on cytology in 101 patients (73 male, 28 female; age 21-78 years) with intrathoracic lesions were compared with a definitive histological diagnosis obtained by thoracotomy. Sixty-one lesions were localized in the right and 31 in the left lung, 5 bilaterally and 4 paramediastinally (maximum diameters: 0.8-12 cm; median: 3.5 cm).

RESULTS

Upon FNA, 69 cases were graded malignant and 17 benign. In the remaining 15 cases the pathologists felt unable to define clearly the cell type or the biological properties, though the material was found representative. Histology yielded 80 malignant and 21 benign lesions, consistent with the cytological diagnosis in 70 cases. In 60 patients accordance between the cellular subtypes suspected after FNA and those found histologically was present. A significantly higher rate of correct FNA diagnoses was made in malignant lesions (chi-square test: p<0.05). The overall diagnostic accuracy of FNA was 0.77, the sensitivity 0.79 and the specificity 0.91 From the surgical point of view, nine resectable lung cancers, three metastases, three other malignancies and three tuberculomas would have been missed by relying on the FNA diagnoses. Eighteen pneumothoraces (nine requiring suction drainage) occurred after FNA.

CONCLUSION

The indication for FNA in otherwise resectable patients should be made carefully, keeping in mind the rate of diagnostic errors and of complications, as well as the possibility for diagnostic VATS of peripheral lesions.

Leukocyte infiltration and secretion of cytokines in pleural drainage fluid after thoracic surgery: impaired cytokine response in malignancy and postoperative complications

STUDY OBJECTIVE

To assess the postoperative course of pleural leukocyte counts and cytokine concentrations in patients with malignant and nonmalignant lung disease who underwent thoracic surgery.

PATIENTS AND INTERVENTIONS

A total of 21 patients undergoing thoracic surgery were included in the study. Twelve patients had a malignant disease, and 9 had a nonmalignant disease. Six patients underwent video-assisted thoracoscopy and 15 underwent thoracotomy. Pleural drainage fluid from the chest tubes was collected postoperatively at Oh, 3h, 6h, 12h, 24h, 48h, 72h, and 96 h. The same schedule, as well as one additional preoperative sample, was applied for blood collections.

RESULTS

A trend toward lower concentrations of tumor necrosis factor-alpha (TNF-alpha), granulocytemacrophage colony-stimulating factor, and interleukin-10 was observed in patients with malignant disease compared to those without malignancy. These differences achieved significance for TNF-alpha in the drainage fluid of those patients with nonmalignant disease who had undergone formal thoracotomy. Patients with malignant disease showed significantly lower macrophage fractions in drainage fluid and lymphocyte fractions in serum. All patients with complications had malignant disease and showed the lowest cytokine concentrations, as well as the lowest fractions of both macrophages in drainage fluid and lymphocytes in serum.

CONCLUSION

The data suggest that malignancy may lead to impairment of the wound-healing process via modification of the inflammatory cell infiltrate and locally released cytokines.

Thoracoscopic procedure for intrathoracic diseases: current status in mainland China

One hundred and five patients underwent a procedure of video-assisted thoracoscopic surgery (VATS) during a period of 5 years, in the Department of Cardiothoracic Surgery, Peking Union Medical College Hospital, Beijing, China. Among them, there were 36 cases suffering from spontaneous pneumothorax, 24 having a nodule of the lung, nine intrathoracic multiple nodules, 10 undefined pleural effusions, eight mediastinal mass, 15 interstitial fibrosis, two pericardial effusion, and one severe emphysema. In all patients of this series, the diagnosis was demonstrated and the suitable management was performed.

[Thoracic actinomycosis--a case report]

BACKGROUND

Actinomycosis is caused by a variety of gram-positive anaerobic or microaerophilic rods belonging to the genus Actinomyces or Propionibacterium. The production of suppurative abscesses or granulomas that eventually develop draining sinuses are hallmarks of the disease. We describe the case of a 55 year old smoker who presented himself 4 months ago with right thoracic pain and an unproductive cough. He developed a warm, red mass in the lower part of the right thorax. We performed an ultrasound guided needle aspiration and the pathologic examination revealed typical sulfur granules and masses of neutrophils in the aspirate. After surgical resection of the abscess and under high-dose therapy with penicillin G the further course of disease was uneventful.

CONCLUSIONS

Although uncommon, thoracic actinomycosis should always taken into account in the differential diagnosis of chronic inflammatory processes that involve the pulmonary parenchyma or pleural space.

Thoracoscopic procedures for intrathoracic diseases: the present status

Thoracoscopic operations, alternatively termed as video-assisted thoracic surgery (VATS), are replacing the variety of surgical procedures which have been otherwise performed by open thoracotomy. The minimally invasive nature of the procedure, reduced postoperative pain, shortened hospital stay, and reduced cost, are the potential advantages of VATS. While these merits are being proven, the limits to this technique are also getting clearer. In fact, VATS has already become a standard treatment of choice in several diseases, such as bullectomy for spontaneous pneumothorax and biopsy for indeterminate nodule and diffuse interstitial lung disease, while others, such as major video-assisted lung resection for lung carcinoma and resection of metastatic lung tumour, await further evaluation of their roles in terms of oncological and technical aspects. Three issues that currently need to be addressed as the present role of thoracoscopy evolves are instrumentation, economics, indication, and end results in certain procedures.

Thoracoscopic procedures for intrathoracic and pulmonary diseases

Since Jacobaeus performed the first thoracoscopy to explore pleural space and mechanically broke pleural adhesions to facilitate the collapse therapy for pulmonary tuberculosis in 1910, numerous thoracic surgeons have been attempting this technique as a means of accomplishing many intrathoracic procedures previously done through open thoracotomy. As the refinement of video technology has advanced, thoracoscopic surgery has played a very important role in thoracic surgery especially since the early 1990s. Because the advantages of video-assisted thoracoscopic surgery for patients include low post-thoracotomy-related morbidity, cosmetic considerations, low pain, earlier post-operative mobilization, and a shorter operation time in some indications, surgeons have been demonstrating its increasing utility in the diagnosis and treatment of the pleura, lung, mediastinum, great vessels, pericardium, and oesophagus. The most common application of the thoracoscopic approach still remains in the management of pleuropulmonary disease. The indications for the thoracoscopic technique are very broad, but its role in the management of primary lung and oesophageal cancer has yet to be confirmed. Thus, the surgeon who uses the technique in these cancerous diseases should be prudent. In conclusion, these thoracoscopic procedures will play more important roles in the practice of thoracic surgery in the future.

[Minimally invasive thoracic surgery--evaluation after 5 years]

A prospective study documented all minimally invasive operations performed in the department of thoracic surgery between 1992 and 1996. The most frequent indications were: lung biopsy (n = 181, 30.9%), coin lesions of unknown origin (n = 179; 30.5%), pneumothoraces (n = 133; 22.7%), pleura effusions (n = 19; 3.2%), and pleura empyema (n = 13; 2.2%). The majority (82.6%) of the minimally invasive procedures were completed without conversion; in 6.0% an extension (< 5 cm) of one of the trocar incisions was necessary and in 11.5% an anterolateral thoracotomy. It is demonstrated that a wide spectrum of thoracic operations can be performed by the minimally invasive approach.

Video assisted thoracoscopic surgery (VATS) in the diagnosis of intrathoracic pathology: initial experience

We report our experience with the use of video-assisted thoracoscopic surgery [VATS] in the diagnosis of intrathoracic disease of unknown origin. In the last two years, 32 patients (18 males) underwent this procedure for diagnostic purposes. Of them, 18 patients had lung pathology, eight mediastinal and six pleural disease. All attempts at achieving a tissue diagnosis were unrewarding. In all of them, diagnostic thoracotomy was being contemplated to procure tissue for histopathological diagnosis. Diagnostic thoracoscopy was successful in providing tissue diagnosis in all the patients with lung disease; seven of the eight patients with mediastinal pathology and five of the six patients with pleural lesions. Diagnostic thoracoscopy was associated with minimal morbidity, short hospital stay, better cosmetic result and quicker return to work as compared to conventional thoracotomy. We conclude that video-assisted thoracoscopy is an excellent diagnostic tool to confirm tissue diagnosis in patients with undiagnosed chest diseases.

[Thoracic hydatidosis. Our experience in the last 15 years]

Hydatidosis in Spain has been a relevant public health problem which has been partly solved due to the implementation of different preventive programs. In this work the thoracic hydatidosis cases diagnosed at our hospital during the last 15 years are reported. Forty patients with thoracic hydatidosis are analyzed. Most of them had pulmonary hydatidosis (32), 14 had liver and lung cysts, and in eight cases of thoracic hydatidosis there was no pulmonary involvement; eight patients had been operated previously because of hydatidosis. A discussion follows of the epidemiologic, clinical and radiologic characteristics, as well as laboratory data, endobronchial changes, diagnostic cost/effectiveness of bronchoscopy when performed, and results after surgery. To remark the high percentage of complicated hydatidosis and uncommon locations, seven cases of multiple hydatidosis (two of them with cardiac involvement), five cases had hepato-thoracic communication, three with chest wall involvement, and one with exclusive cardiac involvement, as well as one case of calcified pulmonary hydatidosis. In most patients (37), treatment was surgery with a low number of complications at post-surgery (3). Three relapses were noted at follow-up.

Primary posterior chest wall echinococcosis

Hydatid cyst is not mentioned among the chest wall tumours in areas not known to harbour echinococcosis. One of the uncommon sites for echinococcosis even in endemic countries is the chest wall. The striking resemblance between neoplasm and hydatid cysts forms a diagnostic dilemma and makes the correct diagnosis essential before surgery.

Noncardiac thoracic surgery in children. A retrospective study

A retrospective study of noncardiac thoracic surgery in children (age < 16 years) comprised 126 patients consecutively operated on over a 10-year period. The surgical procedures included chest-tube insertion for neonatal pneumothorax in 33 children, 12 of whom died within 5 days after birth. Primary intrathoracic disorders were treated in 55 cases, mainly congenital pulmonary malformations in the youngest and traumatic conditions in the oldest. There were no early postoperative deaths in this group, but seven children were dead at the time of follow-up. In 38 children surgery was performed for involvement of intrathoracic organs secondary to other, often malignant diseases. Eleven of these children were dead at follow-up. Noncardiac thoracic surgery is thus required for a number of reasons in children and is well tolerated, although serious primary disease can increase mortality.

Benign intrathoracic tumours. A population survey in northern Finland

Benign intrathoracic tumours are uncommon, but their occurrence in unselected populations is poorly defined. We reviewed all cases of suspected intrathoracic tumour in a population (440,000) in northern Finland during 1990 through 1992. Diagnostic investigations included fiberoptic bronchoscopy and computed tomography in all cases. Of the 653 intrathoracic tumours, 36 were benign. The male/female ratio in these 36 cases was 1.25; the mean age was 54 years. Twenty-three of the lesions were symptomless, found at health check or examination for other disease. Bronchoscopy did not confirm the diagnosis of any benign tumour. Thoracotomy was considered necessary in most cases and histologic diagnosis was therefore available in 24 (67%). Hamartoma was the most common benign lung tumour. This prospective study in an unselected population confirms previous findings in surgical series concerning benign intrathoracic tumours and their histology.

Thoracoscopic surgery

Video-assisted thorascopic surgery has evolved rapidly and has demonstrated utility in the diagnosis and management of a variety of chest disorders. An historical perspective, considerations on patient selection, anesthetic and operative management, and a summary of the Ochsner Clinic institutional experience with this procedure are presented. Special emphasis is given to the treatment of disorders of the autonomic nervous system, esophageal achalasia, and a rare symptomatic congenital pericardial defect. Video-assisted thorascopy provides a promising alternative to many of the more invasive open thoracic surgical procedures.

Castleman disease of the thorax: radiologic features with clinical and histopathologic correlation

PURPOSE

To correlate the radiologic manifestations of thoracic Castleman disease with the clinical and histopathologic features.

MATERIALS AND METHODS

The clinical, surgical, and histopathologic records; chest radiographs; and computed tomographic (CT) and magnetic resonance (MR) images in 30 pathologically proved cases of thoracic Castleman disease were reviewed.

RESULTS

Patients with localized Castleman disease (n = 24) typically had the hyaline-vascular type (n = 23), were asymptomatic (n = 14), and had solitary, well-circumscribed mediastinal masses (n = 24). All lesions at contrast material-enhanced CT (n = 13) enhanced. All lesions at MR imaging (n = 5) were heterogeneous and had increased signal intensity on T1- and T2-weighted images. Three patterns were observed on CT or MR images in 20 patients: a solitary, noninvasive mass (n = 10); a dominant infiltrative mass with associated lymphadenopathy (n = 8); or matted lymphadenopathy without a dominant mass (n = 2). Patients with disseminated Castleman disease (n = 6) typically had the plasma cell type (n = 4), were symptomatic at presentation (n = 5), and had bilateral mediastinal masses on chest radiographs (n = 4). At CT, all lesions manifested with diffuse mediastinal lymphadenopathy. All lesions at contrast-enhanced CT (n = 5) enhanced.

CONCLUSION

Localized Castleman disease manifests as either a solitary, well-circumscribed mediastinal mass or an infiltrative mass with associated lymphadenopathy on CT or MR images. Disseminated Castleman disease manifests with diffuse mediastinal lymphadenopathy.

[The extent of bone resection in osteomyelitis of the chest wall]

The experience in treatment of 40 patients with osteomyelitis and chondritis of the bones of thoracic wall is presented. 39 patients (of 40) underwent surgery with due regard to an adequate extent of resection within so-called borders of intact tissues. Critical analysis of literature and authors' own experience made it possible to establish strict borders of resection of damaged bones in this disease of thoracic wall frame and to obtain good results of combined treatment in patients over 50 years. Complete removal of chondral tissues and resection of bones within the area of probably normal anatomic formation of the bone, irrespective of the origin of osteomyelitis and chondritis (hematogenous, exogenous), have promoted recovery of the patients. There were no relapses during 1-7 year period.

Thoracic actinomycosis: CT findings

PURPOSE

To characterize computed tomographic (CT) findings of thoracic actinomycosis.

MATERIALS AND METHODS

Chest CT scans and radiographs obtained in 22 patients with histopathologically proved thoracic actinomycosis were retrospectively reviewed. All patients were immunocompetent; they were aged 12-73 years (mean, 42.6 years; 14 male, eight female). CT findings were correlated with histopathologic findings in nine patients who underwent surgery (lobectomy [n = 8] or segmental resection [n = 1]).

RESULTS

All of the lesions were unilateral, with an average diameter of 6.5 cm (range, 2-12 cm). Patchy air-space consolidation (n = 20) or a mass (n = 2) was seen on CT scans. Fifteen (75%) of the 20 patients with air-space consolidation had central areas of low attenuation (5-30 mm in diameter) within the consolidation. Thirteen of the 15 patients underwent contrast medium-enhanced CT. Ten (77%) of the 13 patients showed ring-like rim enhancement. Adjacent pleural thickening was seen in 16 patients (73%). At histopathologic examination, central low-attenuation areas at CT were seen as microabscesses with sulfur granules or a dilated bronchus that contained inflammatory cells and Actinomyces colonies. Peripheral enhancement of the low-attenuation areas was wall of the microabscess or surrounding parenchyma composed of granulation tissue rich in vascularity.

CONCLUSION

Findings of chronic segmental air-space consolidation that contained low-attenuation areas with peripheral enhancement or adjacent pleural thickening at CT were suggestive of thoracic actinomycosis.

Cold abscess of the chest wall: a surgical entity?

BACKGROUND

Cold abscesses of the chest wall are rare tuberculous locations. Because of the resurgence of tuberculosis, this diagnosis must be considered more frequently.

METHODS

During a 15-year period (1980 to 1995), 18 patients with one or more cold abscesses of the chest wall were managed in our department. Epidemiologic characteristics, indications, methods and results of operation, and pathogenesis of the abscesses were considered in this retrospective study.

RESULTS

Most of the patients were immigrant men. A previous history of tuberculosis was noted in 15 cases (83%). Six patients had concomitant active pulmonary tuberculosis. There was mostly a solitary lesion in the chest wall, the most frequent location being the rib shaft (60%). Before operation the diagnosis was confirmed only in 4 patients (by needle aspiration of the abscess) and presumed in 4 others: an antituberculous chemotherapy was therefore given preoperatively to 8 patients. One patient did not undergo operation after a favorable response to medical treatment. In the other patients, an operation was indicated because of lack of response in 5 patients and the absence of diagnosis in 12 patients. Adequate debridement and a postoperative antituberculous regimen were performed with recurrence prevention in mind. A follow-up was obtained in 11 of the 17 patients undergoing operation. The only patient who required a second operation because of a recurrence at the same location had refused the antituberculous therapy after the first surgical procedure. Locations of the abscesses, computed tomographic scan results, and histologic examinations are in favor of a lymph-borne dissemination of tubercle bacilli.

CONCLUSIONS

Because fine-needle aspiration remains an inaccurate diagnostic tool and antituberculous medical treatment is not always efficient, chest wall tuberculous cold abscesses remain in most cases a surgical entity.

Video-assisted thoracoscopic surgery: experience with 341 cases

OBJECTIVE

Until recently, thoracoscopy had been used primarily for diagnostic purposes for more than 80 years in thoracic diseases. In this report we reviewed our video-assisted thoracoscopic surgery experience with 341 cases focusing on indications, operative procedures, complications or failure rates.

PATIENTS AND METHODS

Over the last 3 years, we performed 459 video-assisted thoracoscopic procedures. There were 206 male and 135 female patients.

RESULTS

The indications were diagnostic in 171 cases, and therapeutic in 170 cases. There were no operative mortality. Non-fatal complications were seen in 15 cases (4.4%). The mean postoperative stay was 5 days. The specific procedures performed were operations on the pleura (237 cases), lung (158 cases), mediastinum (56 cases) and pericardium (four cases). Conversion to thoracotomy was needed in 43 cases (12.6%). Definitive diagnosis was obtained in 100% of patients with pulmonary nodule/mass or diffuse lung disease, and 95.2% of patients with undiagnosed pleural effusions. The success rate of thoracoscopic approach in non-tuberculous thoracic empyema was 87.3%.

CONCLUSIONS

Video-assisted thoracoscopic surgery is an ideal procedure in the following situations: (1) undiagnosed pleural effusion, (2) recurrent pneumothorax or bullous lung disease, (3) stage II thoracic empyema, (4) lung cancer staging, (5) peripheral pulmonary nodule, and (6) wedge biopsy for diffuse lung disease.

[Two-stage operation in the treatment of severe cicatricial adhesion on submental-thoracic region]

In order to decrease the risk of operation, complete release of scar tissue and reduce the recurrence after operation, from February 1994 to March 1997, seventy-three cases of severe cicatricical adhesion on the submental-thoracic region were treated with release and resection of scar tissue, and delay skin graft. The grafted skin was survived completely after operation. The result from the release of scar tissue of the cervical region was good. The physiological angle of submental-thoracic angle was recovered. It was thought that two-stage operation for submental-thoracic cicatricial adhesion would decrease the risk of operation and be advantageous to the release of contracted soft tissue of anterior cervical region and reduce the recurrence of contracture. The interval between the two stages of the operation was 2 to 3 days, which did not increase the rate of infection of the wound. The shortcomings including increase of pain to patient and prolong the time in hospital.

[Clinical application of 2 mm micro-thoracoscopic surgery]

OBJECTIVE

To determine the clinical safety and efficacy of micro-thoracoscopic surgery.

METHOD

From July 1996 to July 1997, video-assisted thoracoscopic surgery was performed in 47 patients by using 2 mm microthoracoscope. There were 36 males and 11 females. Their age ranged from 40 to 75 years with a mean age of 56.7 years. Surgical procedures included bullectomy (16 patients), wedge resection (3), lung cancer staging (4), lobectomy (2), exploration (15), and resection of mediastinal tumor (2), esophagectomy (1) and repair of pneumothorax (4). Local anesthesia was employed in 18 patients and general anesthesia with double lumen endotracheal tube in 29.

RESULT

There were no operative mortality and postoperative complications.

CONCLUSION

2 mm micro-thoracoscopic surgery could be used in the management of a variety of thoracic conditions. It may be of significant value for diagnostic and therapeutic purposes, but the further study for this new technique is required to determine its safety and efficacy.

Chest wall hamartoma: an alarming chest lesion with a benign course

Chest wall hamartoma is a very rare mass lesion of the chest wall that is manifest at birth or in early infancy with deformity of the thoracic wall and/or varying grades of respiratory distress. The authors report on an 11-month-old infant presenting with chest wall hamartoma who was treated by en bloc excision of the lesion including the involved ribs. They emphasize the importance of early and complete excision of the lesion even in minimally symptomatic patients to avoid lethal respiratory complications, more severe postoperative orthopedic problems, and malignant transformation.

Broncholithiasis and thoracoabdominal actinomycosis from dropped gallstones

We report a case of successfully managed invasive, thoracoabdominal actinomycosis caused by the intraperitoneal spillage of gallstones during laparoscopic cholecystectomy. The infected gallstones traversed the diaphragm, migrated into the lung parenchyma, and obstructed a segmental bronchus, causing pneumonia. Treatment involved retrieval of the obstructing stone, debridement and drainage of the pleuroperitoneal phlegmon/abscess, and intravenous antibiotics. The case illustrates the need to remove gallstones at the time of cholecystectomy.

Analysis of status of surgery in thoracic tuberculosis

A retrospective analysis of the surgical procedure in 1655 patients in twenty years in a university hospital for thoracic tuberculosis revealed that the varieties of procedures were necessary in 2.2% cases only. They can be grouped as tubercular empyema with or without bronchopleural fistula in 1507 (91%), complicated pulmonary tuberculosis in 78 (4.7%), cold abscess in the chest wall with or without lymphadenitis in 54 (3.2%) and osteomyelitis of the ribs and sternum in 16 cases (0.9%). This is statistically significant with a confidence interval of 0.1248 to 0.2348. In tubercular empyema 222 procedures were performed of which 162 were minor procedures, intercostal drainage with irrigation: 89 cases, thoracostoma: 56 cases and continuous chest wall tube 17 cases and 60 were major procedures (decortication in 45 cases, thoracoplasty [modified] in 14 cases and muscle transfer in one case). All the above procedures were preceded by an intercostal drainage. In complicated pulmonary tuberculosis the operative procedures were as follows: lobectomy in 33 cases, pneumonectomy in 35 cases and thoracoplasty in 10 cases. Drainage of cold abscess with or without lymphnode resection was performed in 54 cases and in 16 cases of osteomyelitis of the ribs and sternum resection were necessary. All procedures were performed under the cover of antitubercular therapy and supportive treatment with the aim of resolution of process, obliteration of the empyema space, control of sepsis and improvement of activity performance. The morbidity was extensive and mortality was high in major procedures. Good results could be obtained in over 92% cases, and only 66.2% on major surgery cases.

[Video-assisted thoracoscopy in diagnosis and therapy of intrathoracic diseases]

Video-assisted thoracoscopy has become an important adjunct to traditional thoracic surgical techniques for the diagnosis and therapy of numerous intrathoracic diseases. It has developed to the procedure of choice for patients with spontaneous pneumothorax, indeterminate peripheral lung nodule, diffuse lung disease, pleural disease and effusion and is a valuable alternative to traditional thoracotomy for various indications like the resection of benign intrathoracic tumors and cysts. Although video-assisted thoracoscopy is not recommended for curative therapy of malignancies, it can be useful for the diagnosis, staging and palliation of malignant disease. Video-assisted thoracoscopy should be performed only by surgeons with sufficient experience in thoracic surgery in institutions where adequate prerequisites are available. The clinical impact of video-assisted thoracoscopy is documented by the fact that in centers approximately 20 to 30% of all thoracic surgical procedures currently are performed with this new technique.

[A case of nodular fasciitis of the chest wall]

We present a case of nodular fasciitis of chest wall origin. A 62-year-old woman visited our hospital because of a rapidly growing hard tumor fixed to her right chest wall, measuring 7 x 8 cm in size. Although incisional biopsy specimen revealed that the tumor was suggestive of nodular fasciitis, the possibility that the tumor had a malignant component could not be excluded. Total excision of the mass with combined resection of 3rd, 4th, 5th ribs was performed to establish the histological diagnosis and treatment plan. We believe that the tumor proved to be malignant by excisional biopsy, should then undergo further excision with sufficient surgical margin. Nodular fasciitis may be misdiagnosed as a sarcoma due to its rich cellularity, mitotic activity and poorly circumscribed nature. Awareness of the histological features of nodular fasciitis, and its predilection for presenting as a rapidly growing mass, should decrease the likelihood of misdiagnosis and the attendant risk of over surgery.

A case of chest wall Castleman's disease

We describe the findings of a rare case of right anterior chest wall Castleman' s disease of the hyaline vascular type. It manifested as a solitary mass, 7.5 x 4.5 x 3.0 cm in size, with incomplete border and extrapleural signs on chest roentgenograms. The mass was hypoechoic with numerous tiny bright spots on US; it enhanced homogeneously on CT, had a homogeneously high intensity on both T1- and T2-weighted MR images, and showed rich vascularity with homogeneous capillary blush on internal thoracic arteriogram.

[A case of intrathoracic chronic expanding hematoma]

A chronic expanding hematoma in the thoracic cavity is very rare and is clinically included in a category of chronic hemorrhagic empyemas as a special type of chronic empyemas in Japan. In this paper, we report a case of this disease. The patient was a 69-year-old female, who was underwent bilateral artificial pneumothorax for pulmonary tuberculosis 35 years ago. On 25. Nov. 1996, she admitted into Nagoya University Hospital for a diagnosis of intrathoracic tumor. On 2. Dec. 1996, we removed the tumor with combined resection of left lower lobe. The tumor was diagnosed pathologically as an intrathoracic chronic expanding hematoma. This disease is benign, but progressive clinically. In progressive case it is dangerous to remove the tumor for a risk of excessive bleeding and hard adhesion to the chest wall. So we think the earlier is a surgical treatment, the better is a management for this disease.

[Content of haptoglobin in blood serum in patients after thoracic surgery for various indications]

Initial results are presented on the usefulness of haptoglobin content monitoring in blood serum of patients after thoracic operations performed for various indications. 57 patients were analysed and divided into 3 groups based on the type of disease. Group 1 consisted of patients operated for malignant neoplasm. Group 2 consisted of patients with inflammatory changes and purulent complications within the thorax. Group 3 consisted of patients operated from other indications. The experimental samples of further 30 operated patients have not been analysed yet due to a delay in shipment of plates from Boehringer. The control group consisted of 31 healthy volunteers. In the experimental groups blood was taken 1 day before and 1, 3, 7, 10 and 14 days after the surgical intervention and in the case of complications-21 and 30 days after surgery. Erythrocyte sedimentation, leucocyte level, serum haptoglobin content, clinical and radiological data were analysed. Haptoglobin content was measured using the radial immunodiffusion method according to Manchini. Results were analysed statistically. The increase in serum haptoglobin content in patients after thoracic surgeries and after purulent complications, shows that haptoglobin is a sensitive acute phase indicator and its monitoring may be useful in evaluating the disease process. In advanced neoplastic processes haptoglobin content is a reflection of the progression of the disease process.

Symmetrical necrotising chest wall infection following paronychia

Paronychial infection is a common condition seen in the accident and emergency department. Treatment is by antibiotics or incision and drainage under local anaesthetic. Complications are rare but may occur if treatment is delayed or inadequate. A case is described of symmetrical necrotising chest wall infection, of unusual anatomical distribution, that occurred following a paronychia and required surgical debridement and skin grafting.

Meconium thorax: a case report and review of literature

A case is presented in which extension of meconium peritonitis through muscular defects in the diaphragm lead to intrathoracic calcifications diagnosed sonographically at 23 weeks of gestation. There were three diaphragmatic defects, two small ones corresponded to foramina of Morgagni and one large posterior defect that did not correspond to the foramen of Bochdelak. There were three additional muscular defects: one in the rectus abdominus and two, bilaterally, in the loins. Despite long-standing fetal ascites and fresh intraperitoneal meconium at laparotomy, postoperative progress was uneventful. The baby did not have other dysmorphic features except for a single palmar crease, the chromosomes were normal, and the baby did not have cystic fibrosis. Follow-up examination at 10 months showed a thriving infant with mild hypotonia and developmental delay, but no respiratory or gastrointestinal problems.

[Surgery of thoracic and pulmonary tuberculosis and the sequelae of its treatment in adults]

Surgery for tuberculosis was the starting point for thoracic and cardiovascular surgery in the modern day, but its place was more and more restricted to the treatment of the disease. Excisions (lobectomies, pneumonectomies, segmentestomies) currently represent the majority of operations, after this come operations on the pleura (decortication) and rarely those on the thoracic wall (thoracoplasty, parietectomy). The indications for excision are principally encountered with disease of the parenchyma itself: progressive disease under treatment or with resistant tubercle bacilli, sequelae of parenchymal complications (infections, aspergilloma or haemoptysis) and certain forms of atypical mycobacteria, and also a small but significant group in which excisions are aimed at diagnosis. Sometimes excisions are associated by necessity with decortication for pleural disease which may or may not have originally been intended for the underlying parenchyma or the lesions may be the sequelae of previous complications of treatment such as collapse therapy. Occasionally surgery is indicated in the treatment of lymph node masses in the mediastinum which have not responded to antituberculous therapy and during the treatment bronchial complications have evolved or there have been other sequelae. As for the indications for surgery of the thoracic wall such as thoracoplasty, they appear more than ever obsolete and even if they are still used in certain complications of surgery, they have apart from a few exceptions, lost their original therapeutic role in tuberculosis. However, currently there is a recrudescence of tuberculosis favoured by certain socio-economic situations and strengthened by the appearance of TB cultures which are more and more resistant. The surgery of tuberculosis in its oldest forms (thoracoplasty and removal of cavities) can no longer be said to be the surgery of the past. They proved in the old days that they could cure. Surgery has once more its place in the therapeutic arsenal of new forms of the disease and indirectly in limiting the risk of spread it has a role to play in prevention.

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication

This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis.

CASE HISTORY

A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation.

[Video-assisted thoracoscopic surgery--indications, technique and results]

Video-assisted thoracoscopic surgery became an important tool in the surgical treatment of various thoracic disease. Currently many interventions which routinely required thoracotomy can be performed by VATS safely and with excellent results. This includes pleurectomy, decortication, wedge-resection, bullectomy and volume reduction surgery for emphysema, biopsy and/or resection of mediastinal tumors, thymectomy for myasthenia gravis, sympathectomy and even lobectomy. The benefit of thoracoscopic surgery is reduced postoperative pain, including diminished impairment of pulmonary function, shorter hospital stay and the more rapid recovery.

Unusually located hydatid cysts: intrathoracic but extrapulmonary

BACKGROUND

Hydatid cyst disease is still a problem in Turkey, as well as in many other places in the world. Extrapulmonary location of the disease in the thorax is very rare, and surgical procedures can be considered that differ from those used for pulmonary hydatid cysts.

METHODS

We reviewed retrospectively our experience in the surgical treatment of 22 patients with intrathoracic, extrapulmonary hydatid cysts. In our department, 297 patients with thoracic hydatid cysts were managed surgically in the last 14 years, in 22 (7.4%) of whom the cysts were localized extrapulmonarily in the thorax. The locations of these hydatid cysts were a fissure, the pleural cavity, chest wall, mediastinum, myocardium, and diaphragm.

RESULTS

Total resection was chosen as the surgical procedure in all patients except 4 (18.2%), 1 of whom had cystectomy and capitonnage for cardiac hydatid cyst and 3 of whom had cystectomy and local curettage for cysts located in the chest wall. Empyema developed postoperatively in 1 case (4.5%) with a cyst in the fissure. The follow-up period was 1 year, and there were no deaths.

CONCLUSIONS

Hydatid cyst may be found in many different sites, including extrapulmonarily in the thorax, and bearing this in mind will facilitate planning of the operation.

Chronic expanding hematoma in the chest

We herein report the successful surgical treatment of 2 cases of chronic expanding hematoma in the chest. The first patient, who had undergone thoracoplasty 42 years earlier due to tuberculosis, became aware of a slowly growing mass protruding in the lateral thoracic wall. The second patient, who had tuberculous pleurisy 36 years earlier, was referred to our department because of a slowly expanding intrathoracic mass revealed by a roentgenogram. The tumors, which were encapsulated chronic hematomas, were both surgically resected. These cases are rare because of the development of a very large mass after undergoing treatment for tuberculosis more than 30 years previously.