Video-assisted thoracoscopic surgery (VATS) in the diagnosis and treatment of intrathoracic diseases at Ratchaburi Hospital.

OBJECTIVE: To review the authors' experience and benefit in diagnosis and management of intrathoracic diseases by Video-assisted thoracoscopic surgical procedures (VATS) using a non trocar technique. MATERIAL AND METHOD: Retrospective review of sixty-eight consecutive patients who underwent seventy-one VATS procedures between January 1997 and December 2004. Indications included recurrent or persistent pneumothorax (n = 21 patients), empyema thoracis (17), lung nodules or masses (8), clot haemothorax (6), pleural effusion (4), pleural thickening or masses (3), mediastinal masses or cysts (3), pericardial effusion (2), removal of bullets from the pleural cavity (2), bronchiectasis with hemoptysis (1) and inspection of diaphragmatic injury (1) (Table. 1). An alternative method of manipulating thoracoscopic instruments without using a trocar was described. RESULTS: Of the 71 VATS procedures in 68 patients, 62 (87.3%) procedures were successfully performed in 59 patients. Three of them underwent VATS bilaterally. (1 Tuberculous empyema and 2 spontaneous pneumothorax). Four patients requried conversion to thoracotomy due to bleeding in 1 who had excision lung bleb, extensive adhesion in 2 with chronic empyema thoracis and unlocated lesion in 1 with solitary pulmonary nodule (SPN). There were 5 postoperative complications: prolonged air leak for more than 7 days was seen in 4 patients. This complication occurred in a patient with spontaneous pneumothorax (3 patients) and bilateral tuberculous empyema at the left side (1 patient). Wound infection and mild effusion occurred in 1 patient with unilateral tuberculous empyema (no additional drainage was required). VATS in diagnostic procedures were effective in 90% (9 of 10 patients) and the procedures were 4 wedge excision, 3 pleural biopsies, 1 wedge excision for interstitial lung disease 1 inspection of diaphragmatic injury and 1 required conversion. Sixty one therapeutic procedures were effective in 50 patients (85.9%) (50 of 58 patients). None of them had a recurrence of pneumothorax after VATS procedures or other complications. Only small doses of analgesics were needed. There was no intraoperative mortality. The mean operative time was 67 minutes and the average postoperative hospital stay was 5.4 days for successful VATS group. CONCLUSION: VATS using of a non-trocar technique is a safe and effective method for diagnosis and treatment of intrathoracic diseases. Patients had benefit in reduced postoperative pain, short hospitalization, short recovery times and good cosmetic result.

Management of tracheobrochial injuries: a 10-year experience at Ratchaburi hospital.

BACKGROUND AND OBJECTIVE: Tracheobronchial injuries are rare but life threatening. Their successful diagnosis and treatment require a high level of suspicion and early surgical repair The authors review their experience in managing these injuries over the past 10 years. MATERIAL AND METHOD: Patients who were admitted to the Thoracic Surgical Unit, Ratchaburi Hospital and treated for tracheobronchial injuries from 1993 to 2004 were included in the present study. Hospital records were reviewed on mechanism of injury, clinical presentation, diagnosis, management and outcome. RESULTS: The present series comprised of 11 tracheobronchial injury patients. Causal mechanism of injury was 4 blunt and 7 penetrating injuries. 4 of them with blunt injury, there were 3 right main bronchial disruptions, 1 minor cervical laceration. Presenting signs included dyspnea in 4 and subcutaneous emphysema in 3. 1 of them had massive air leak. Radiographic finding were pneumomediastinum in 3. Pneumothorax in 2, Atelectasis of right lung in 1. All of the right bronchial disruptions had primary repair with reanastomosis in 2 and resection of stenotic bronchus with reanastomosis in 1; this patient developed empyema thoracis with Acinetobacter iwoffii as a result of delayed diagnosis (40 day). One patient with minor cervical laceration underwent conservative treatment. All patients with blunt injuries were discharged with a normal patency of airway. 7 patients with penerating injuries, there were 4 cervical, 1 cervical associated with esophageal injury, 1 combined cervical-thoracic type of injuries and 1 Thoracic injury. Presenting signs included dyspnea in 7 and subcutaneous emphysema in 6. The radiographic finding were pneumomediastinum in 5 pneumothorax in 4, one patient underwent tracheal reanastomosis. The rest of six patients underwent immediate primary repairs. One patient with cervical knife stap wound died 4 hours postoperatively of hemoptysis, progressive hypoxia and aneuria, 6 of them were recovered with a normal patency of airway CONCLUSION: The authors concluded that, result of treatment for tracheobronchial injury should depend upon the mechanism of injury, early recognition, early diagnosis and appropriate surgical intervention. Delay in diagnosis is the single most important factor-influencing outcome. Common complications in the early phase were hypoxia, organ failure while in the late phase were sepsis, tracheal or bronchial stenosis, mediastinitis and chronic bronchopleural fistula, etc.

Outcome after transsternal radical thymectomy for myasthenia gravis: 14-year review at Ratchaburi Hospital.

OBJECTIVE: To determine predictability factors, clinical features and outcome in the patients after transsternal radical thymectomy (TRT) for Myasthenia Gravis (MG). METHOD: A 14-year retrospective review (1990-2004) and analysis of medical data on 32 patients with MG who underwent TRT. Two patients were lost to follow-up. Preoperative medication included anticholinesterase drugs and steroids. Plasmaphereses were used in 2 cases before operation. The modified Osserman clinical classification (Table 1) was used to define disease severity. The status of the patients was evaluated as follows: A (remission), B (improvement), C (no change), D (deterioration), E (death due to myasthenia gravis). Using univariate analysis, sex, age, onset, Osserman class and pathology correlated with outcome and statistical significance is defined as P < 0.05. RESULTS: Among the 30 patients in the present study with MG who underwent TRT women comprised 70% (21 of 30 patients), and mean age was 42.87 +/- 12.16 year (19-65 years). The preoperative duration of the disease ranged from 0.5 to 120 months (mean = 25.72 +/- 30.68 months). Clinical statuses of patients as assessed on initial evaluation were 13 patients (43.3%) were in class IIA, 6 (20%) in class IIB, and 11 (36.7%) in class III. (Table 2) The histology of thymus glands consisted of hyperplasia in 22 patients, normal in 2, atrophic thymus in 3, thymomas in 3, (2 were malignant thymomas). Hospital mortality was 0, but 9-month mortality was 3.33% (1 of 30 patients). The mean follow-up period was 41.80 +/- 53.89 months. Complete remission (A) was achieved in 40% of patients (12 of 30), and marked improvement (B) of MG in 40% (12 of 30), for a total benefit rate of 80%. 6.7% (2 of 30) were unchanged (C), 10% (3 of 30) were worse (D) and 3.3% died because of MG (E). Using univariate analysis on sex, clinical status by Osseman classification, and histopathology correlated significantly with outcome (P < 0. 05); 95.2% of women (20 of 21) benefited from the procedure, versus 44.4% of men (4 of 9). 100% (19 of 19) of patients in class IIA and IIB benefited from the procedure, versus 45.5% (4 of 9) of patients in class III. All patients with thymoma presented a less favorable outcome (deteriorated in 2, and died in 1) versus 11.1% (3 of 24) of patients without thymomas were deteriorated. CONCLUSION: The remission and improvement in 80% of patients suggested that adequate thymic tissue were removed with radical thymectomy. Female, absence of thymoma, thymic hyperplasia, patients in class IIA, and IIB (non-respiratory involvement) are favorable predictability prognostic factors.

Severe sand aspiration: a case report with complete recovery.

A 5-year-old boy, previously healthy, was admitted to Ratchaburi Hospital after being buried in a sand pile. He presented with dyspnea and tachypnea. Chest radiograph showed opaque particles in both main and segmental bronchi (sand bronchogram). The first attempt of bronchoscopy was unsatisfactory as a considerable amount of sand particles had migrated further into the distal bronchi. A second bronchoscopy was performed with 0.9% saline lavage. Most of the sand particles were successfully removed. Intravenous steroids and antibiotics were administered for treatment. The patient was discharged uneventfully by the end of the first week of hospitalization.