Determination of the optimal surgical procedure by identifying risk factors for pneumonia after transthoracic esophagectomy

BACKGROUND

Esophagectomy is associated with a high risk of postoperative complications, and the respiratory complications are the most common. Therefore, stratification of patients based on preoperative risk factors is essential. This study aimed to identify the risk of postoperative pneumonia (POP) based on the preoperative factors and determine the optimal perioperative surgical management strategy.

METHODS

This retrospective study involved 207 patients who underwent esophagectomy. The patients were divided into two groups, namely, with POP and without POP. To identify the risk factors for POP, the pre- and perioperative characteristics were analyzed. A receiver operating characteristics curve was used to determine a cutoff value of 2.40 L for the forced expiratory volume in 1 s (FEV1.0) and the cohort was divided into a high- and low-FEV1.0 group. A second analysis was then performed to determine the optimal surgical management for patients at a high risk for POP.

RESULTS

POP occurred in 45 (21.7%) patients. A multiple logistic regression analysis showed that FEV1.0 was significantly lower in the POP (+) group (P = 0.020); thus, a low FEV1.0 was found to be a risk factor for POP. Multiple logistic regression analysis showed that open thoracotomy was a significant risk factor for POP in low FEV1.0 patients (P = 0.013).

CONCLUSIONS

A low FEV1.0 and an open thoracotomy are risk factors for POP. Therefore, patients with low FEV1.0 should be managed carefully and video-assisted thoracic surgery should be considered.

Randomized controlled trials are needed to test videothoracoscopy versus thoracotomy for lung cancer lobectomy

3rd Mediterranean Symposium on Thoracic Surgical Oncology, Catania, Italy, 21-22 April 2016 Surgeons presented their experience on videothoracoscopic lobectomy at the 3rd Mediterranean Symposium on Thoracic Surgical Oncology. The audience did not question that lobectomy could be done safely and as completely by videothoracoscopic techniques provided it was in expert and practiced hands and suitable patients. The question addressed here is whether video-assisted thoracic surgery can replace thoracotomy as a standard of care in patients suitable for either approach. To determine which provides the better outcome in terms of long-term survival with equivalent quality of life, would require direct comparison in pragmatic randomized controlled trials.

[Possibilities of improving of videothoracoscopic operations for spontaneous pneumothorax]

A 15-years experience of videothoracoscopic operations in the treatment of 616 patients, suffering spontaneous pneumothorax, was summarized. The methods of videothoracoscopic operations, depending on the volume and localization of pathological process in pulmonary tissues, were depicted. The stages of endoscopic surgical intervention for spontaneous pneumothorax were analyzed. The disease recurrence, while using videothoracoscopic operations, have occurred in 3.6% of patients. All the patients are alive.

[Causes and results of repeated videothoracoscopy]

For 7 years videothoracoscopies for diseases and traumas of the chest were fulfilled in 2075 patients, abscessoscopy in 27 patients. Repeated videothoracoscopies were fulfilled in 41 (2%) patients operated for spontaneous pneumothorax, pleural empyema, exudative pleurisy and injuries to the chest due to recurrent hydropneumothorasx, prolonged abundant release by drainage, bleedings by drainage or formation of clotted hemothorax, not effectiveness of sanation, of the empyema cavity, reabscessoscopy - in 2 patients. Revideothoracoscopies were divided into groups with the presence of drainages or removed drainages according to the terms - into emergent (on the first day, immediately after the development of complications), urgent (from 2 to5 days), postponed (from 6 to 15 days), and late (more than 15 days). In 4 cases the conversion to minithoracotomy had to be done due to continuing bleeding, the absence of lung hermetism. All patients with spontaneous pneumothorax, pleuritis and chest trauma recovered. Lethal outcome was in 1 (2.4%) case from lung artery thromboembolism. It was concluded that revideothoracoscopy was an alternative thoracotomy of full value in reinterventions.

How much skill should we need for a VATS lobectomy in stage I lung cancer? An evaluation of surgeon groups

Although there has been progress in video-assisted thoracic surgery (VATS), there have been no reports about the skill needed to perform this surgery for patients with stage I lung cancer. We reviewed a randomized series of surgeons in a single institution and attempted to identify the quality of skill needed in this surgery. Cases of surgery on clinical stage I non-small cell lung cancer (NSCLC) involving 103 patients (56 VATS and 47 conventional approach) from January 2000 to April 2006 were assessed for eligibility. We reviewed these patients and placed them in random order into three surgeon groups (groups A, B, and C) that were based on surgeons who had performed 50 lobectomies through thoracotomy. Three patients were converted to a thoracotomy. Of the remaining 53 patients, 17 were in group A, 15 were in group B, and 21 were in group C. There were no significant differences between the three surgeon groups regarding technical factors such as blood loss and operation time. After a short initial learning period, two of the three surgeon groups significantly decreased total blood loss. Morbidity and recurrence did not differ between the groups, and there was no mortality in our sample. The volume of VATS operations performed by individual surgeons who have had good training in open lobectomy may not make for a positive impact on clinical outcomes. The decision for a VATS lobectomy in cases of stage I NSCLC should not be limited only by a surgeon's thoracoscopic experience.

Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome

BACKGROUND CONTEXT

Video-assisted thoracoscopic surgery (VATS) is a new technique that allows for access to anterior spinal pathology using a minimally invasive approach. Proponents of this procedure argue that anterior thoracic spine surgery can be performed with the same accuracy and completeness as is possible by the conventional open approach but through much smaller skin and muscle incisions. Advantages of VATS include decreased blood loss, shorter hospital stay, and improved cosmesis.

PURPOSE

To detect if VATS is equally as effective as open thoracotomy, both combined with instrumented posterior spinal fusion, with respect to fusion rate, percent curve correction, and functional outcome.

STUDY DESIGN

Retrospective case control.

PATIENT SAMPLE

Seventeen patients underwent VATS/instrumented posterior spinal fusion for thoracic curvatures exceeding 50 degrees . A control cohort of patients that were age matched, sex matched, and curve magnitude matched underwent open thoracotomy/instrumented posterior spinal fusion.

OUTCOME MEASURES

Percentage of curve correction, fusion rate, intraoperative and postoperative clinical parameters, and functional outcome scores.

METHODS

Preoperative and postoperative radiographs were analyzed to calculate the percentage of major curve correction in the coronal and sagittal planes as well as the rate of fusion. In addition, operative reports and medical records were analyzed for the following outcomes: estimated operative blood loss, length of surgery, chest tube output, length of hospitalization, and complications. Average follow-up time was 26 months in the VATS group and 27 months in the thoracotomy group. Finally, functional outcome was assessed using the Scoliosis Research Society (SRS-22) and Oswestry Disability Index (ODI) scoring system.

RESULTS

The VATS group (mean age, 30) averaged 5.4 anterior levels and 11 posterior levels fused. The thoracotomy group (mean age, 32) averaged 5.8 anterior levels and 12 posterior levels fused. Estimated blood loss was nearly identical for the posterior procedures in both groups, whereas the anterior blood loss was significantly higher in the thoracotomy group as compared with the VATS group (541 cc vs. 288 cc). Operative time did not differ significantly between the two cohorts. Percent curve correction immediately postoperative (52% correction VATS; 51% correction thoracotomy) as well as at the 2-year follow-up (50% VATS and 54% thoracotomy) was nearly identical. There was no difference in postoperative ODI (p=.6) or SRS scores (p=.5) between groups. Complications were frequent but not significantly different between the two groups (p=.3).

CONCLUSION

VATS is equally effective as thoracotomy with respect to fusion rate, major curve correction, and functional outcome scores. Although a decrease in operative blood loss was seen in the VATS patients, this was not clinically significant.

Video-Assisted Thoracoscopic Surgery in the Treatment of Chest Trauma: Long-Term Benefit

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has gained an increasing importance as a diagnostic and therapeutic tool in chest trauma. Several studies have demonstrated its feasibility and safety, but only a few addressed the long-term benefit of VATS. The aim of this study was to evaluate the short-term and long-term benefits of VATS in chest trauma, with emphasis on the patient's point of view.

METHODS

Medical records of patients with chest trauma during a 10-year period were reviewed. The study included 77 patients (37 patients in the VATS group and 40 in the thoracotomy group). Forty-four patients who underwent operative treatment during the study period were excluded from the study. Hospital charts and a telephone questionnaire were used to evaluate the outcome.

RESULTS

No deaths occurred in either group. Clotted hemothorax was the most common finding. The incidence of wound and pulmonary complication were higher in the thoracotomy group. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia. Average time to resume normal activity was shorter in the VATS group. More than 2 years after discharge, the rate of return to a normal lifestyle was 81% in the VATS group and 60% of the thoracotomy group. Patients in the VATS group were generally more satisfied with their health status and surgical scars.

CONCLUSIONS

The results of this study show that for stable patients with chest trauma, video assisted thoracic surgery is feasible and safe. Moreover, it is tolerated better than open thoracotomy, has a favorable postoperative course, a superior long-term outcome, and greater patient satisfaction.

Histomorphometric assessment of thoracoscopically assisted anterior release in a porcine model: safety and completeness of disc discectomy with surgeon learning curve

STUDY DESIGN

A retrospective study using histomorphometric analysis to quantify the percentage of discectomy following thoracoscopic anterior release and fusion in a porcine model.

OBJECTIVE

To investigate the safety and completeness of disc and endplate removal with respect to the learning curve of the surgeon in a porcine thoracoscopic anterior fusion model.

SUMMARY OF BACKGROUND DATA

The thoracoscopic approach has been used to perform an anterior release and fusion before an open posterior instrumentation, however, there is concern that the technique may not provide sufficient visualization or exposure to perform safely and completely.

METHODS

A total of 32 pigs (160 discs) were assigned to 2 groups (early experience, n = 16; late experience, n = 16), and underwent 5 level thoracoscopic anterior release followed by anterior instrumentation and fusion from T5 to T10. At 4 months after surgery, the spines were harvested, and each discectomy disc was histomorphometrically analyzed to determine the percentage of disc excision and amount of endplate removal.

RESULTS

There were no significant differences in the percent disc excision between the early (67% +/- 11%) and late groups (69% +/- 10%). Greater than 50% of the disc was excised in 151 of 160 discectomies (94%). Both superior and inferior endplates were resected in 92 of 160 disc levels (57%). The amount of endplate removal had improved over time in both early and late groups (P < 0.0001). The histologic examination revealed no evidence for posterior longitudinal ligament disruption or spinal canal encroachment in any disc.

CONCLUSIONS

Video-assisted thoracoscopic discectomy is safe and allows for a significant amount of disc material excision. This study did not demonstrate a learning curve with respect to the amount of disc material excised, but a learning curve was seen for endplate excision.

[Video-assisted thoracoscopy for diagnosis and therapy of pulmonary, mediastinal and pleural neoplasia in children and adolescents]

Data are presented on 30 cases of video-assisted thoracoscopy for different intrathoracic neoplasms in children and adolescents. Indications and contra-indications for use for diagnostic and therapeutic purposes as well as possible complications and their prophylaxis are discussed.

Developing a VATS lobectomy programme--can VATS lobectomy be taught?

OBJECTIVE

Although VATS lobectomy has been demonstrated to be safe and effective, the technique is not widely practiced. This may, in part, reflect difficulty in acquiring appropriate skills. We have evaluated the effect of experience and training on surgical outcomes during the development and establishment of a VATS lobectomy programme.

METHODS

Data were collected prospectively on 276 consecutive VATS lobectomies under the care of a single consultant as either the primary surgeon or supervising four trainees. The series was divided into cohorts of 46 patients. These comprised one trainee cohort and five sequential consultant cohorts. Statistical analysis utilised standard tests of significance.

RESULTS

Increasing experience with the VATS lobectomy programme was associated with a significant reduction in operating time but intraoperative blood loss and postoperative stay were not influenced by increasing consultant surgical experience. Training was associated with a mean increase of 22 min operative time (p=0.0005) but no increase in intraoperative blood loss, morbidity, mortality or postoperative stay. The 46 trainee operative times were similar to the first 46 consultant cases.

CONCLUSIONS

VATS lobectomy can be safely taught to trainee thoracic surgeons. However, in view of the limited number of centres undertaking VATS lobectomy, training should be coordinated at a national level to concentrate experience and improve uptake of this technique.

Video-assisted thoracic surgery is minimally invasive, but is it less traumatic?

BACKGROUND

Video-assisted thoracic surgery (VATS) is a minimally invasive procedure. This study aimed to evaluate whether the procedure is less traumatic to the ipsilateral non-diseased lobe(s) than open thoracotomy (OT) during pulmonary resection by a comparison of alveolar-capillary membrane (A/C) permeability.

METHODS

Wedge resections were performed in twenty-seven patients with various types of primary and secondary malignant, solitary, pulmonary nodules. Fifteen patients had OT, while 12 patients had VATS. (99 m)Tc-DTPA radioaerosol studies were performed on the day before surgery and on the third or fourth day postoperatively. The images of the ipsilateral non-diseased lobe(s) were compared.

RESULTS

Postoperatively, all patients had significantly increased A/C permeability at the ipsilateral non-diseased lobe(s). However, the degree of increase in the VATS group was the same as that of the OT group. Postoperative A/C permeability of the contralateral lung was not significantly different.

CONCLUSIONS

Both procedures caused injury to the ipsilateral non-diseased lobe(s) in terms of A/C permeability at the same degree. Although VATS has been considered as a minimally invasive procedure, the trauma caused by VATS to the "disease-free lung" is the same as that caused by open thoracotomy.

Surgical lung biopsy for diffuse pulmonary disease: experience of 196 patients

OBJECTIVE

Surgical lung biopsy is considered the final method of diagnostic modality in patients with undiagnosed diffuse pulmonary disease. Nevertheless, the effect of surgical lung biopsy on the diagnosis, treatment, and outcome of the patient still remains controversial. This study reviewed the experiences of surgical lung biopsies in 196 consecutive patients during the past 7 years.

METHODS

Surgical lung biopsy was performed after achievement of general anesthesia through video-assisted thoracoscopic surgery or a 7-cm minithoracotomy. Biopsy specimens were swabbed for aerobic and anaerobic bacterial, fungal, and mycobacterial cultures. The sections of specimens were routinely stained with hematoxylin and eosin, and acid-fast, Gomori methenamine silver, Gram stain, or other special stains were added if necessary.

RESULTS

The pathologic diagnosis after surgical lung biopsy included infection (30.6%), interstitial pneumonia or fibrosis (21.9%), diffuse alveolar damage (17.3%), neoplasm (13.3%), autoimmune diseases (8.2%), and others (8.2%). After surgical lung biopsy, 165 (84.2%) patients had changes in their therapy, 124 (63.3%) patients had clinical improvement of their conditions, and 119 (60.7%) patients survived to hospital discharge. Comparison between immunocompromised and immunocompetent patients showed that diagnosis of infection was significantly higher ( P < .01) in the former group (41.2% vs 20.2%). In addition, there was no significant difference in the distribution of diagnosis and rate of change in therapy between the respiratory failure and nonrespiratory failure groups. However, the rates of response to therapy and patient survival were significantly lower in the respiratory failure group (51.2% and 41.5%) than in the nonrespiratory failure group (71.9% and 78.1%, P < .05). There was no surgical mortality directly related to the procedure. The surgical morbidity rate was 6.6%.

CONCLUSION

Surgical lung biopsy is a safe and accurate diagnostic tool for diffuse pulmonary disease. For a large proportion of the patients, change of therapy and then clinical improvement can be achieved after surgical lung biopsy. Surgical lung biopsy should be considered earlier in patients with undiagnosed diffuse pulmonary disease, especially when the respiratory condition is deteriorating.

Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials

OBJECTIVES

To determine if video assisted thoracic surgery is associated with better clinical outcomes than thoracotomy for three common procedures: surgery for pneumothorax, minor resections, and lobectomy.

DESIGN

Systematic review of randomised clinical trials.

DATA SOURCES

Medline, Embase, Cochrane database of systematic reviews, Cochrane controlled trials register. Reference lists of relevant articles and reviews.

METHODS

Criteria for inclusion were random allocation of patients and no concurrent use of another experimental medication or device. At least two authors performed and confirmed data abstraction and analyses. Information on quality of trials, demographics, frequency of the events, and numbers randomised were collected.

RESULTS

12 trials randomised 670 patients. Video assisted thoracic surgery was associated with shorter length of stay (reduction ranged from 1.0 to 4.2 days) and less pain or use of pain medication than thoracotomy in the five out of seven trials in which the technique was used for pneumothorax or minor lung resection. In the treatment of pneumothorax, video assisted thoracic surgery was associated with substantially fewer recurrences than pleural drainage in two trials (from 20 to 53 events prevented per 100 treated patients). No substantial advantages were observed for video assisted thoracic surgery in lobectomies.

CONCLUSIONS

Video assisted thoracic surgery is associated with better outcomes and seems to have a complication profile comparable with that of thoracotomy for the treatment of pneumothorax and minor resections. As for lobectomy, further studies are needed to determine how it compares with thoracotomy.

[A clinical evaluation of the practical reliability in video-assisted thoracic surgery for right primary lung cancer]

Recently, lobectomy by video-assisted thoracic surgery (VATS lobectomy: VL) has been widely applied to peripheral lung cancer because of its less invasive approach compared to standard thoracotomy (ST). However, the appropriate approach in VL still remains to be solved. The aim of this study was to evaluate the practical reliability of our technical devices in VL for right primary lung cancer. For the VATS procedures, a mini-thoracotomy measuring about 6-7 cm was made in the fourth or fifth intercostal space (ICS) under the auscultatory triangle without rib resection. Two access holes 12 mm in size were also made in the fourth ICS at the anterior axillary line and in the seventh ICS at the posterior axillary line, respectively. These access holes were used for insertion of thoracoscope, endoscopic stapler or retracting instrument according to operative procedure. After stapling of the vessels and bronchus, the resected pulmonary lobe was removed from the thorax using a plastic retrieval bag. The present study showed the technical feasibility of this unique thoracoscopic approach in the standard lobectomy with systematic nodal dissection for right lung cancer.

A survey of 150 video-assisted thoracoscopic procedures in Kuwait

OBJECTIVE

To review our experience of indications, technique, and complications as they relate to video-assisted thoracoscopic surgery (VATS) in the diagnosis and management of intrathoracic diseases.

SUBJECTS AND METHODS

One hundred and fifty consecutive VATS procedures, which were performed over a 3-year period, were retrospectively evaluated. Indications included recurrent or persistent primary spontaneous pneumothorax (n = 73 patients), lung biopsies for diagnosis of diffuse lung disease (n = 33), pleural biopsies (n = 18), wedge resections of pulmonary nodules (n = 8), bilateral thoracic sympathectomy (n = 6), decortication (n = 5), mediastinal tumor biopsies (n = 5), excision of bullous emphysema (n = 1), and removal of a foreign body from the pleural cavity (n = 1). An alternative method of manipulating thoracoscopic instruments without using a trocar is described.

RESULTS

Of the 150 VATS procedures, 127 (85%) were successfully performed, 6 (4%) were converted to thoracotomy and 17 (11%) had complications. The most common complication was prolonged air leak, which occurred in 9 patients. The average postoperative hospital stay was 4 days (range: 2-17). Diagnostic procedures were considered successful in 32 out of 33 lung biopsies and in all 18 patients with pleural diseases, 8 lung nodules, or 5 mediastinal tumor biopsies. The other 86 therapeutic VATS procedures were effective in 82 (95%) patients. Four (5%) patients had a recurrence of the pneumothorax after VATS.

CONCLUSION

Thoracoscopy and the use of a nontrocar technique is a safe and effective method for the diagnosis and treatment of intrathoracic diseases.

Clinical value of video-assisted thoracoscopy for preoperative staging of non-small cell lung cancerA prospective study of 105 patients

This study prospectively evaluated the usefulness of thoracoscopy for staging non-small cell lung cancer in 105 consecutive patients. A comparison was made of TNM stage grouping classification according to clinical disease, thoracoscopic data, and pathological findings. In 40 (38%) patients, thoracoscopy was unreliable for assessing extent of disease due to pleural symphysis. In 13 T1 clinical lesions, thoracoscopy was unreliable in 5, clinical and thoracoscopic staging concurred in 4, but 4 cases changed to T2. In 62 T2 clinical lesions, thoracoscopy was not feasible due to technical difficulties in 21 (34%); however, in the remaining 41 cases, 6 lesions changed to T3 and 1 to T4. In the group of 23 T3 or T doubtful clinical disease, thoracoscopy was conclusive, whereas in 12 T4 clinical lesions, thoracoscopy contributed for tailoring treatment strategies. With regard to N stage, 72 N0 clinical cases, thoracoscopy revealed false negatives in 25%. N1 clinical lesions were not evaluated due to the small number of patients. In 30 N2 clinical lesions, thoracoscopy was incomplete in 11. In another 11 cases, mediastinal node involvement at nodal groups not accessible by mediastinoscopy was confirmed by thoracoscopy. Clinical and thoracoscopic findings were not concurrent in eight cases, therefore in clinical N2 lesions, the diagnostic accuracy of thoracoscopy was 63%. Only one case of unsuspected pleural metastasis was detected. Thoracoscopy-related complications occurred in nine cases. In summary, video-assisted thoracoscopy was useful for staging T3, T4, and T doubtful clinical disease as well as N2 lesions especially for the surgical exploration of lymph nodes at the lower paratracheal level (region 4), aortopulmonary window (region 5), paraaortic (region 6), posterior subcarinal space (region 7), paraesophageal (region 8), and inferior pulmonary ligament (region 9).

Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results

BACKGROUND

The efficacy of thoracoscopic radical esophagectomy for cancer of the thoracic esophagus and the learning curve required have yet to be clearly established.

METHODS

Eighty treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm minithoracotomy and four trocar ports. The outcomes in the first 34 patients (group 1) and the last 46 patients (group 2) were compared.

RESULTS

There were no differences in background or clinicopathologic factors between the two groups. The duration of the thoracoscopic procedure and blood loss were less (p <0.0001), the incidence of postoperative pulmonary infection was less (p = 0.0127), and the number of mediastinal nodes retrieved was greater (p = 0.0076) in group 2. Multivariate analysis demonstrated that surgical experience (number of cases performed) predicted the risk of pulmonary infection (p = 0.0331).

CONCLUSION

Video-assisted thoracoscopic radical esophagectomy can be performed with safety and efficacy comparable to those of open esophagectomy. Morbidity decreases with the surgeon's experience.

[Video-assisted thoracoscopy (VATS) during the last ten years (1992-2001)]

We summarize and analyse the video-assisted thoracoscopies (VATS) performed in our department during the last ten years. In this period 296 patients underwent VATS for diagnosis or therapy. We describe indications, advantages and disadvantages, we also analyse the complications. Video-assisted thoracoscopy is less demanding to the patients than thoracotomy, it reduces the length and cost of inpatient treatment. We recommend extensive use of VATS in suitable patients.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

The role of video-assisted thoracoscopic surgery in the diagnosis of the small peripheral pulmonary nodule

BACKGROUND

The use of imaging techniques to detect small peripheral pulmonary nodules often results in a missed diagnosis. Thoracoscopy had limited application until recently, when advances in technology allowed thoracic surgeons greater visualization and mobility within the chest.

METHODS

Between September 1992 and June 1997, 81 patients were treated for small peripheral pulmonary nodules by pulmonary wedge excision using video-assisted thoracoscopic techniques. The patients were 39 men and 42 women with an average age of 59.5 years.

RESULTS

A definitive diagnosis was obtained in all cases. Malignancies were found in 44 patients (55%), which involved primary lung cancer in 28 patients and metastatic lesions in 16 patients. The rate of malignancy in nodules measuring 1 cm or less was 18%. There was no operative mortality or morbidity.

CONCLUSIONS

We conclude that video-assisted thoracoscopic lung biopsy is a more effective and less invasive diagnostic tool for small peripheral pulmonary nodules.

Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline

OBJECTIVE

A panel was convened by the Health and Science Policy Committee of the American College of Chest Physicians to develop a clinical practice guideline on the medical and surgical treatment of parapneumonic effusions (PPE) using evidence-based methods.

OPTIONS AND OUTCOMES CONSIDERED

Based on consensus of clinical opinion, the expert panel developed an annotated table for evaluating the risk for poor outcome in patients with PPE. Estimates of the risk for poor outcome were based on the clinical judgment that, without adequate drainage of the pleural space, the patient with PPE would be likely to have any or all of the following: prolonged hospitalization, prolonged evidence of systemic toxicity, increased morbidity from any drainage procedure, increased risk for residual ventilatory impairment, increased risk for local spread of the inflammatory reaction, and increased mortality. Three variables, pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry, were used in this annotated table to categorize patients into four separate risk levels for poor outcome: categories 1 (very low risk), 2 (low risk), 3 (moderate risk), and 4 (high risk). The panel's consensus opinion supported drainage for patients with moderate (category 3) or high (category 4) risk for a poor outcome, but not for patients with very low (category 1) or low (category 2) risk for a poor outcome. The medical literature was reviewed to evaluate the effectiveness of medical and surgical management approaches for patients with PPE at moderate or high risk for poor outcome. The panel grouped PPE management approaches into six categories: no drainage performed, therapeutic thoracentesis, tube thoracostomy, fibrinolytics, video-assisted thoracoscopic surgery (VATS), and surgery (including thoracotoiny with or without decortication and rib resection). The fibrinolytic approach required tube thoracostomy for administration of drug, and VATS included post-procedure tube thoracostomy. Surgery may have included concomitant lung resection and always included postoperative tube thoracostomy. All management approaches included appropriate treatment of the underlying pneumonia, including systemic antibiotics. Criteria for including articles in the panel review were adequate data provided for >/=20 adult patients with PPE to allow evaluation of at least one relevant outcome (death or need for a second intervention to manage the PPE); reasonable assurance provided that drainage was clinically appropriate (patients receiving drainage were either category 3 or category 4) and drainage procedure was adequately described; and original data were presented. The strength of panel recommendations on management of PPE was based on the following approach: level A, randomized, controlled trials with consistent results or individual randomized, controlled trial with narrow confidence interval (CI); level B, controlled cohort and case control series; level C, historically controlled series and case series; and level D, expert opinion without explicit critical appraisal or based on physiology, bench research, or "first principles."

EVIDENCE

The literature review revealed 24 articles eligible for full review by the panel, 19 of which dealt with the primary management approach to PPE and 5 with a rescue approach after a previous approach had failed. Of the 19 involving the primary management approach to PPE, there were 3 randomized, controlled trials, 2 historically controlled series, and 14 case series. The number of patients included in the randomized controlled trials was small; methodologic weaknesses were found in the 19 articles describing the results of primary management approaches to PPE. The proportion and 95% CI of patients suffering each of the two relevant outcomes (death and need for a second intervention to manage the PPE) were calculated for the pooled data for each management approach from the 19 articles on the primary management approach. (ABST

Defining the pediatric spinal thoracoscopy learning curve: sixty-five consecutive cases

STUDY DESIGN

Consecutive case prospective chart and radiographic review.

OBJECTIVES

The purpose of this study was to define the learning curve of spinal thoracoscopy.

SUMMARY OF BACKGROUND DATA

Thoracoscopy is an alternative to open thoracotomy in the treatment of pediatric spinal deformity. The learning curve for spinal thoracoscopy has not been described.

METHODS

In this prospective study 65 consecutive cases of thoracoscopic anterior release with discectomy and fusion performed by one surgeon for the treatment of pediatric spinal deformity were reviewed. The patients were, on average, 14 +/- 3 years old and had the following diagnoses: idiopathic scoliosis (n = 13), Scheuermann's kyphosis (n = 9), neuromuscular spinal deformity (n = 35), congenital scoliosis (n = 4), and tumor/syrinx (n = 4).

RESULTS

The average operative time for the thoracoscopic procedure was 161 +/- 41 minutes (range, 50-240 minutes). There was a slight decrease in the average operative time as the series progressed. The average number of discs excised was 6.5 +/- 1.5 (range, 3-10), and the number increased as the series progressed. The average operative time per disc was 29.3 +/- 7.7 minutes in the first 30 patients compared with 22.3 +/- 4.7 minutes in the next 35 patients (P < 0.01). The average blood loss during the thoracoscopic procedure was 301 +/- 322 mL (range, 25-2000 mL) and did not decrease as the series progressed. Initial postoperative scoliosis and kyphosis corrections were 59% +/- 17% and 92% +/- 12%, respectively. Complications occurred in six patients (cases 4, 8, 17, 31, 39, and 46) and were evenly distributed throughout the series.

CONCLUSIONS

The learning curve for thoracoscopy is substantial, but not prohibitive. This technique provides a safe and effective alternative to thoracotomy in the treatment of pediatric spinal deformity.

Is there a future for minimally invasive cardiac surgery?

Although cardiac surgery has made significant contributions to the cardiac health of millions of patients over the past 40 years, it has evolved from an 'emerging growth' to a 'mature' industry. Along with this maturation has come an 'inertia of success' and lack of innovation. Minimally invasive cardiac surgery is an attempt to develop more patient friendly cardiac procedures yet maintain the superior long term results of conventional cardiac surgery. A broad spectrum of new surgical techniques and technical innovations has been fostered. The impact has been not only that of 'discontinuous innovation' of a new type of cardiac surgery but also a significant 'coat-tail' effect of 'upgrading' conventional cardiac surgery. It is difficult to adapt to change. But if we maintain an open-mindedness toward evolution with a firm foundation in proven standards, our patients will be the beneficiaries.