Catamenial pneumothorax: surgical repair of the diaphragm and hormone treatment

Catamenial pneumothorax is defined as spontaneous pneumothoraces occurring within 72 h before or after onset of menstruation. It is rare but clinical index of suspicion should be high in ovulating women with spontaneous pneumothoraces. The mechanism is unclear but is thought to involve pre-existing or acquired diaphragmatic defects and endometrial implants. Traditional therapy involving hormonal treatment or surgical pleurodesis alone is associated with high rates of recurrence. A series of four patients with catamenial pneumothorax managed at our institution is presented to highlight the condition to various surgical specialties to whom it may present, and to emphasise the importance of both surgical and hormonal interventions in preventing recurrence. Each patient underwent video-assisted thoracoscopic inspection of the diaphragm, mechanical pleurodesis and, most importantly, repair of diaphragmatic defects with an artificial mesh. Surgical treatment was strictly followed by a course of gonadotrophin-releasing hormone analogue therapy in three patients, with no recurrence to date (longest follow-up 45 months). The fourth patient suffered a postoperative recurrence when hormonal treatment was delayed for 6 weeks, stressing the importance of hormonal treatment in conjunction with surgery.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Open thoracotomy and decortication for chronic empyema

OBJECTIVES

Traditionally, chronic empyema has been treated by thoracotomy and decortication. Some recent reports have claimed similar clinical results for videothoracoscopy, but with less morbidity and mortality than open procedures. Our experience with thoracotomy and decortication is reviewed so that the results of this surgical procedure can be adequately evaluated.

MATERIALS AND METHODS

From March 1992 to June 2006, 85 patients diagnosed with empyema were treated at Santo Tomás Hospital by the first author. Diagnosis of chronic empyema was based on the duration of signs and symptoms before definitive treatment and imaging findings, such as constriction of the lungs and the thoracic cage. Thirty-three patients fulfilled the criteria for chronic empyema and underwent open thoracotomy and decortication.

RESULTS

Twenty-seven patients (81.8 %) were male and the average age of the study group was 34 years. The etiology was pneumonia in 26 patients (78.8%) and trauma in 7 (21.2%). The duration of symptoms and signs before definitive treatment averaged 37 days. All patients had chronic empyema, as confirmed by imaging studies and operative findings. Surgery lasted an average of 139 min. There were 3 (9%) complications with no mortality. The post-operative length of stay averaged 10 days. There were no recurrences of empyema.

CONCLUSIONS

Open thoracotomy and decortication can be achieved with low morbidity and mortality. Long-term functional results are especially promising. We suggest that the validation of other surgical approaches should be based on comparative, prospective and controlled studies.

Catamenial pneumothorax - a review of the literature

Catamenial pneumothorax should be defined as recurrent accumulation of air in the pleural cavity in reproductive-age women without concomitant respiratory diseases. The sine qua non criterion is the occurrence of the pneumothorax in the period of 72 hours before or after the menses. Additional criteria include characteristic pleural lesions, right-sided occurrence, and coexistence of endometriosis. There are no radiological or pathological conditions allowing an exact confirmation of catamenial pneumothorax. In the case of catamenial pneumothorax, treatment failure most commonly consists in disease recurrence. It may occur even as late as several years after the initial treatment. The recurrence rate in patients undergoing surgery ranges from 8% to 40%. Finding and resecting the visible pleural lesions is of key importance during surgical treatment. Reconstruction of the diaphragm must be performed in every patient in whom diaphragmatic perforations are found. Hormonal therapy seems to be effective in sustaining the effects of surgical treatment.

Technique of the transcervical-subxiphoid-videothoracoscopic maximal thymectomy

Background:

The aim of this study is to present the new technique of transcervical-subxiphoid-videothoracoscopic “maximal”thymectomy introduced by the authors of this study for myasthenia gravis.

Materials and Methods:

Two hundred and sixteen patients with Osserman scores ranging from I–III were operated on from 1/9/2000 to 31/12/2006 for this study. The operation was performed through four incisions: a transverse 5–8 cm incision in the neck, a 4–6 cm subxiphoid incision and two 1 cm incisions for videothoracoscopic (VTS) ports. The cervical part of the procedure was performed with an open technique while the intrathoracic part was performed using a video assisted thoracoscopic surgical (VATS) technique. The whole thymus with the surrounding fatty tissue containing possible ectopic foci of the thymic tissue was removed. Such an operation can be performed by one surgical team (the one team approach) or by two teams working simultaneously (two team approach). The early and late results as well as the incidence and localization of ectopic thymic foci have been presented in this report.

Results:

There were 216 patients in this study of which 178 were women and 38 were men. The ages of the patients ranged from 11 to 69 years (mean 29.7 years). The duration of myasthenia was 2–180 months (mean 28.3 months). Osserman scores were in the range of I–III. Almost 27% of the patients were taking steroids or immunosuppressive drugs preoperatively. The mean operative time was 201.5 min (120–330 min) for a one-team approach and it was 146 (95–210 min) for a two-team approach (P < 0.05). While there was no postoperative mortality, the postoperative morbidity was 12%. The incidence of ectopic thymic foci was 68.4%. The rates of complete remission after one, two, three, four and five years of follow-up were 26.3, 36.5, 42.9, 46.8 and 50.2%, respectively.

Conclusion:

Transcervical-subxiphoid-VTS maximal thymectomy is a complete and highly effective treatment modality for myasthenia gravis. The need for sternotomy is avoided while the completeness of the operation is retained.

Early-term postoperative thoracic outcomes of videothoracoscopic vertebral body tethering surgery

Background

This study aims to discuss the early-term postoperative thoracic complications in videothoracoscopic anterior vertebral body tethering surgery.

Methods

The study included 56 patients (3 males, 53 females; mean age 12.6 years; range, 10 to 16 years) operated with a total of 65 videothoracoscopic anterior vertebral body tethering surgeries between April 2014 and November 2018. Surgical indications were adolescents with different growth potentials, who had thoracic, thoracolumbar or double curves less than 70°. Surgical details and postoperative thoracic complications were recorded.

Results

Forty-two patients were administered thoracic tether, whereas five and nine patients were administered thoracolumbar tether and both approaches concomitantly, respectively. Two patients developed ipsilateral total atelectasis, one patient contralateral lobar atelectasis, one patient chylothorax, one patient pleural effusion, and one patient pneumothorax after chest drain removal. Overall thoracic complication rate was 9.2% and 30-day readmission rate was 1.8%. All patients achieved their rehabilitation goals.

Conclusion

Videothoracoscopy-assisted anterior vertebral body tethering is a safe and efficient technique that yields low complication rates. Early postoperative functional results are promising with high patient satisfaction. Pre- and postoperative respiratory rehabilitation may decrease thoracic complication rates.

Video-assisted thoracoscopic treatment of primary spontaneous pneumothorax in older children and adolescents

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively rare condition in the pediatric population lacking of specific recommendations regarding the management. Video-assisted thoracoscopic surgery (VATS) has gained widespread consensus during the last 10 years. We retrospectively reviewed our experience of VATS in the treatment of pediatric patients affected by PSP in terms of timing of surgery, operative technique, and postoperative outcome.

METHODS

Between 1998 and 2014, 58 pediatric patients were treated for PSP. Treatment consisted in pulmonary apicectomy in all patients and pleurodesis. Patients received either apical pleurectomy and mechanical pleurodesis or mechanical pleurodesis alone.

RESULTS

Mean age was 16.6 ± 1.6 years (range 10-18) with a male/female ratio of 5:1. Seventeen patients underwent surgery after the first episode of PSP. Apical pleurectomy and mechanical pleurodesis was performed in 30 patients while others received mechanical pleurodesis alone. Conversion to open surgery was needed in four procedures (6.9%). Postoperative complications occurred in 1.7% of cases. Sixteen patients received more than one procedure for contralateral pneumothorax (15 cases) and postoperative recurrence (1 case). The mean follow-up was 95 ± 63 months. Recurrence rate was 12.1%. Univariate analysis showed that recurrence was significantly correlated with younger age (P = 0.044) and postoperative chest tube (P = 0.027). Both univariate and multivariate analysis showed that apical pleurectomy did not prevent recurrences.

CONCLUSIONS

VATS is an effective procedure for PSP in pediatric patients. Apical pleurectomy does not seem to prevent recurrence. Due to the increased risk of recurrence of PSP in younger patients, indication to VATS after the first episode might be considered. Pediatr Pulmonol. 2016;51:713-716. © 2016 Wiley Periodicals, Inc.

Video-assisted thoracic surgery complications

Video-assisted thoracic surgery (VATS) is a miniinvasive technique commonly applied worldwide. Indications for VATS are very broad and include the diagnosis of mediastinal, lung and pleural diseases, as well as large resection procedures such as pneumonectomy. The most frequent complication is prolonged postoperative air leak. The other significant complications are bleeding, infections, postoperative pain and recurrence at the port site. Different complications of VATS procedures can occur with variable frequency in various diseases. Despite the large number of their types, such complications are rare and can be avoided through the proper selection of patients and an appropriate surgical technique.

Videothoracoscopic resection for lung cancer: moving towards a "standard of care"

Videothoracic surgery for lung cancer is now an established practice but there is a division of opinion between surgeons whose aim is to spare all patients a thoracotomy and those who have not adopted videoscopic methods for routine lobectomy. The latter remain in the majority; most patients at present have a thoracotomy. Surgeons from Europe and America met in Catania, Sicily at the 3(rd) Mediterranean Symposium on Thoracic Surgical Oncology to explore the evidence and the routes to making videothoracoscopic surgery a standard of care. Evidence from one completed randomized controlled trial (RCT) and several propensity score matching studies indicate that less invasive surgery is at least as safe as thoracotomy. By the accepted standards of an oncological lobectomy which include clearance of the primary cancer and the intended lymphadenectomy or sampling, the operations are equivalent. Clinical effectiveness in achieving long-term cancer free survival is likely. However, the co-existance of videothoracoscopy has encouraged smaller non-muscle cutting incisions and the avoidance of rib spreading, narrowing whatever gap there may have been in terms of the patients' experience.

The Efficacy of VATS and Intrapleural Fibrinolytic Therapy in Parapneumonic Empyema Treatment

BACKGROUND

Development of multiloculation-septation is a challenging entity in empyema patients. In this study, it is aimed to investigate the success rates of videothoracoscopic deloculation (VATS-D) and intrapleural fibrinolytic (IPFib) application after tube thoracostomy.

METHODS

The study retrospectively examined the patients diagnosed with empyema with multiloculation and septation between January 2005 and December 2014. Among these patients, the study included those who received VATS-D or IPFib therapy.

RESULTS

VATS-D (Group 1) was applied to 54 patients and IPFib (Group 2) was applied to 24 patients. The success of both procedures was evaluated considering the need of decortication in the following periods. In the VATS-D group, 4 (7.4%) patients required decortication via thoracotomy where it was 1 (4.1%) patient (p = 0.577) in the IPFib group. The length of hospital stay was 6.81 ± 2.55 (4-15) days in Group 1 compared to 14.25 ± 6.44 (7-27) days in Group 2 (p <0.001).

CONCLUSIONS

It was demonstrated that both of the methods applied in the study have high efficacy and are preferable methods based on the general conditions of patients. Additionally, the shorter length of hospital stays in patients received VATS-D was established as a significant parameter.

Catamenial Pneumothorax as the First Expression of Thoracic Endometriosis Syndrome and Pelvic Endometriosis

Objective: The menstrual-related catamenial pneumothorax (CP) can be the first expression of thoracic endometriosis syndrome (TES), which is the presence of endometriotic lesions in the lungs and pleura, and pelvic endometriosis (PE). This study aims to analyze our experience with this specific correlation describing our multidisciplinary approach to CP. Methods: Hospital records of 32 women, operated for CP at our Department from January 2001 to December 2021 were reviewed. Surgical treatment consisted of videothoracoscopy and laparoscopy when indicated. Results: TES and PE were diagnosed in 13 (40.6%) and 12 (37.5%) women, respectively. The association of TES and PE was present in 11 cases (34%). Fifteen patients (46.9%) underwent laparoscopy, of which 11 concurrently with videothoracoscopy. Most of the patients affected had stage III–IV endometriosis (40.6%). All patients received hormonal therapy after surgery. Five patients with PE conceived spontaneously resulting in six live births. The mean follow-up was 117 ± 71 months (range 8–244). Pneumothorax recurrence occurred in six patients (18.8%). At present, all women are asymptomatic, with no sign of pneumothorax recurrence. Conclusions: CP might be the first expression of TES and/or PE. A multidisciplinary approach is advocated for optimal management of the disease.

Videothoracoscopic identification of chondromatous hamartoma of the lung

Introduction

The main disadvantage of a videothoracoscopic procedure is the lack of touch sensation. The probability of easily finding the lesion is usually estimated according to computed tomography (CT).

Aim

To find useful parameters of location of chondromatous hamartoma of the lung parenchyma in relation to its size to assess the probability of successful search via a videothoracoscopic approach only.

Material and methods

A group of 55 patients operated on for chondromatous hamartoma of the lung at the First Department of Surgery in Olomouc from January 2006 to June 2011 was analyzed. Initially, the tumor's longest diameter and its nearest distance to the pleural surface were measured on CT scans. Subsequently, the surgery began using the videothoracoscopic approach. A short thoracotomy with direct palpation followed when videothoracoscopy failed.

Results

No significant differences in age, sex and side of localization between the group with and without successful videothoracoscopic detection were found. A significant difference was found in the median size (p = 0.026) and the depth of the tumor (p < 0.0001) and in the calculated index “tumor size/depth” (p < 0.0001). Deeper analysis revealed that the parameters “depth” and “index size/depth” are considered to be good predictors but the parameter “size” is not a suitable predictor.

Conclusions

The main predictors of successful videothoracoscopic detection of lung chondromatous hamartoma are considered to be the depth of the tumor in the lung parenchyma with a cut-off value ≤ 7.5 mm and the index “size/depth” with a cut-off value ≥ 1.54; the tumor size is not considered to be a good predictor.

Thoracoscopic repair of esophageal atresia with a distal fistula - lessons from the first 10 operations

Introduction

Thoracoscopic esophageal atresia (EA) repair was first performed in 1999, but still the technique is treated as one of the most complex pediatric surgical procedures.

Aim

The study presents a single-center experience and learning curve of thoracoscopic repair of esophageal atresia and tracheo-esophageal (distal) fistula.

Material and methods

From 2012 to 2014, 10 consecutive patients with esophageal atresia and tracheo-esophageal fistula were treated thoracoscopically in our center. There were 8 girls and 2 boys. Mean gestational age was 36.5 weeks and mean weight was 2230 g. Four children had associated anomalies. The surgery was performed after stabilization of the patient between the first and fourth day after birth. Five patients required intubation before surgery for respiratory distress. Bronchoscopy was not performed before the operation.

Results

In 8 patients, the endoscopic approach was successfully used thoracoscopically, while in 2 patients conversion to an open thoracotomy was necessary. In all patients except 1, the anastomosis was patent, with no evidence of leak. One patient demonstrated a leak, which did not resolve spontaneously, necessitating surgical repair. In long-term follow-up, 1 patient required esophageal dilatation of the anastomosis. All patients are on full oral feeding.

Conclusions

The endoscopic approach is the method of choice for the treatment of esophageal atresia in our center because of excellent visualization and precise atraumatic preparation even in neonates below a weight of 2000 g.

Videothoracoscopy in the treatment of benign neurogenic tumours of the posterior mediastinum

Introduction

The indications for videothoracoscopy are very broad and include the treatment of mediastinal tumours.

Aim

To present our experience of using the minimally invasive technique in treating benign neurogenic tumours.

Material and methods

Twenty-two patients were treated due to tumours of the posterior mediastinum from 2003 to 2012. The size of the tumours ranged from 2 cm to 25 cm. Tumours up to the size of 6 cm were treated using videothoracoscopy (VT), bigger ones through thoracotomy.

Results

The videothoracoscopy technique was used in 17 patients, thoracotomy in 5. In 2 cases conversion was required due to adhesions in the pleural cavity preventing VT treatment. Complications related to the procedure were not observed. The average time of hospital stay after VT treatment was 4 days, while after thoracotomy it was 6 days. Histologically, tumours of benign nature were found in all cases. Schwannoma was diagnosed in 15 patients, ganglioneuroma in 3 patients, neurofibroma in 3 patients, and chemodectoma in 1 patient. None of the 3 cases of neurofibroma was associated with Recklinghausen's disease. At a mean follow-up of 60 months no recurrence of the tumour was found.

Conclusions

In the case of tumours up to 6 cm the best surgical technique is videothoracoscopy. In the case of large tumours the best access is the open technique. The minimally invasive technique allows one to shorten the patient's treatment time, reduce postoperative pain and obtain a good cosmetic effect of the treatment.

Modalities of Diagnosis and Management of Peritoneal Dialysis-related Hydrothorax Including Videothoracoscopy-assisted Repair: A Single-center Experience

Continuous ambulatory peritoneal dialysis (PD)-related hydrothorax (PDRH) is uncommon; however, it is associated with a high discontinuation rate and morbidity. We report clinical characteristics, pleural fluid chemistry patterns, diagnostic modality, management options, and outcomes in 12 patients who have confirmed pleuroperitoneal communication after the inception of the PD program at our institute. The incidence of PDRH in our study was 0.64%. The interval between initiation of PD and hydrothorax ranged from 7 weeks to 40 weeks (average 20.6 weeks). Ten (83.3%) had right-sided, one (8.3%) left-sided, and one (8.3%) bilateral hydrothorax. Most patients (83.3%) had dyspnea with chest symptoms, but two (16.6%) patients were asymptomatic. All patients had confirmed communication either by peritoneal scintigraphy or computed topography peritoneography. PD had to be stopped in two patients and patients were shifted back to hemodialysis. Pleurodesis, through thoracostomy with tetracycline or betadine, was used for four patients. Three patients underwent video-assisted thoracoscopy (VATS) with surgical repair of the diaphragmatic defect, and one underwent VATS assisted talc pleurodesis. All four patients who underwent VATS repair of the defect had successful outcomes. With availability and experience with VATS, most patients had successfully returned to PD with no recurrence and with minimal morbidity.

VATS Group ERAS Registry

Enhanced recovery after surgery (ERAS) is a multimodal, polyhedral approach to surgical management for patients undergoing surgical therapy. Since ERAS is not a specific procedure, these protocols are not exclusively created for particular clinical settings but they are prone to be adapted to a large variety of healthcare programs after surgery. ERAS Society was the platform in which a new multidisciplinary methodology to promote a fast recovery, a considerable patient involvement and resource optimization has been developed. ERAS Society has also produced guidelines for different surgical specialties and has already generated some evidence regarding preoperative, intraoperative and postoperative practice. ERAS in Thoracic Surgery has had a slow-growing development but some hints suggest that introducing ERAS methodology in pulmonary resections for cancer could be feasible and effective with potential tangible benefits for patients, families, caregivers and welfare. There is no evidence yet concerning ERAS principles in Thoracic Surgery; for this reason, a new possibility for prospective data collection and analysis is created using the VATS Group Web Registry in which additional records, documents and facts have now the possibility to be registered and eventually explored to possibly adjust the ERAS protocols to major pulmonary resections.

[Hyperhidrosis: treatment, results, problems]

OBJECTIVE

To analyze the results of thoracic sympathectomy for hyperhidrosis.

MATERIAL AND METHODS

The study included 166 patients aged from 15-51 years. There were 118 women and 48 men. Isolated palmar hyperhidrosis was observed in 46 patients, axillary - 46 patients, palmar-axillary - 74 cases. Video-assisted thoracic bilateral sympathectomy was performed. In patients with palmar hyperhidrosis, sympathetic chain was transected between the ribs II and III, axillary and palmar-axillary hyperhidrosis - between the ribs III and IV.

RESULTS

Intraoperative injury of intercostal artery occurred in 1 case. Cautery was effective. Postoperative complications occurred in 4 (2.4%) patients (pneumothorax followed by drainage for up to 2-3 days). Symptoms of hyperhidrosis disappeared early after surgery in all cases. Long-term results were followed in 47 patients. Persistent positive effect and patient satisfaction with postoperative outcome were noted in 44 (93.6%) cases. Recurrences occurred in 2 patients with palmar hyperhidrosis and 1 patient with axillary hyperhidrosis for the period from 2 weeks to 6 months. Compensatory sweating developed in 26 (55.3%) patients (within several weeks up to 6 months). Mild compensatory sweating occurred in 17 patients, moderate - 8 patients, severe - 1 patient. Compensatory sweating was more common in patients with axillary and palmar-axillary hyperhidrosis compared to those with isolated palmar hyperhidrosis (p<0.05). We found no significant difference in the incidence of compensatory sweating depending on the level of sympathetic chain intersection (p>0.05).

CONCLUSION

An effectiveness of thoracic sympathectomy for hyperhidrosis is obvious. Compensatory sweating is the main undesirable consequence of this surgery. Prediction and prevention of compensatory sweating are not possible. It is imperative to warn the patient about possible compensatory sweating.

Video-Assisted Thoracoscopic Surgery Lobectomy for Pulmonary Malignant Melanoma Metastasis

Malign melanoma (MM) develops as a result of malign transformation of the melanocytes and constitutes 2-4% of all skin cancers, while being the most common cause of mortality among all skin cancers. In addition to other organs, distant organ metastases also include lung metastasis. A metastasectomy is an acceptable treatment option in cases of malign melanoma with isolated lung metastasis. The current report presents a case with isolated lung metastasis that underwent a right upper VATS (video-assisted thoracoscopic surgery) lobectomy due to tumour localization.

[Thoracoscopic resection of mediastinal parathyroid gland]

According to the modern literature, mediastinal parathyroid glands are diagnosed in 2-20% of cases. In the available Russian-language literature, there are few reports on successful resection of mediastinal parathyroid glands in impossible surgery through cervical approach. Despite the development of minimally invasive surgical approaches and their advantages, traumatic sternotomy was used in these cases. We report a successful thoracoscopic resection of mediastinal parathyroid gland in a patient with persistent hyperparathyroidism. Preoperative topical diagnosis was essential for successful surgery. Favorable postoperative outcome was confirmed by regression of symptoms and vascular calcification, as well as improved densitometric parameters in one year after surgery.

[Thoracoscopic repair of posttraumatic phrenic hernia in 62 years after injury of the diaphragm]

Diagnosis of diaphragmatic injury is difficult in some cases. Symptoms of chronic posttraumatic diaphragmatic hernia are very diverse and associated with dysfunctions of the displaced abdominal organs and compression of thoracic organs. Previous blunt or open chest and abdominal trauma, as well as visible scars as a result of injury should be considered. Treatment concept assumes surgical correction of posttraumatic diaphragmatic hernia. Choice of surgical approach and type of intervention are determined individually. Despite the global trend towards minimally invasive endoscopic surgery, there are few reports on thoracoscopic correction of posttraumatic phrenic hernia. The authors report a rare case of thoracoscopic correction of posttraumatic diaphragmatic hernia in an 81-year-old man in 62 years after abdominal injury. Assuming degenerative changes in tissues and risk of defect enlargement following suture eruption, we used titanium nickelide reinforcing protectors. Video-assisted double port thoracoscopic access allowed minimally traumatic and successful correction of diaphragmatic hernia, that ensured early medical and social rehabilitation of the patient.