[Video-assisted thoracoscopic anatomic lung resection: experience of 246 operations]. / Videotorakoskopicheskie anatomicheskie rezektsii legkikh: opyt 246 operatsii.

AIM: To present one of the largest materials of video-assisted thoracoscopic (VATS) anatomic lung resections in Russia. MATERIAL AND METHODS: It is a retrospective analysis of treatment of 246 patients who underwent VATS anatomic lung resection for the period from 2010 to 2014 at the Center for Thoracic Surgery of St. Petersburg Clinical Hospital №122. One surgical team has operated 125 men and 121 women aged from 20 to 85 years (58.8±13.4 years). There were 216 (87.8%) lobectomies, 4 (1.6%) bilobectomies, 9 (3.7%) pneumonectomies, 10 (4.1%) segmentectomies and 7 (2.8%) trisegmentectomies. Upper right-side lobectomy was the most frequent in this group (87 (40.3%)). Most of operations was performed via 2 approaches (119 patients). Average length of the longest incision was 4.3±0.93 cm (range 2-6 cm). All patients were examined according to a single plan. FEV1 less than 70% was observed in 26% of patients; comorbidity index was 5 scores or more in 24% of cases; 23.2% of patients were older than 70 years. RESULTS: Non-small cell lung cancer (NSCLC) was diagnosed in 168 patients (68.3%), pulmonary tuberculosis - in 27 (11%), chronic suppurative lung disease - in 27 (11%) cases. Furthermore there were 9 cases of pulmonary metastases, 11 cases of carcinoid, 1 - MALT-lymphoma, 1 - leiomyoma, 2 - small cell lung cancer, as well as one case of IgG-associated pseudotumor. Among 168 cases of NSCLC operations were performed in 87 (51.8%) cases for cancer stage I, in 46 (27.3%) patients for stage II, in 27 patients for stage III (including 16 cases of stage IIIA and 11 cases of stage IIIB). 8 patients (4.7%) with lung cancer stage IV have been operated in radical surgery for solitary metastasis. Mean duration of surgery was 202.1±58.2 minutes (range 100-380). On the average 12.8±5.6 (range 9-32) mediastinal lymph nodes were excised during lymph node dissection in cancer patients. Mean number of nodes groups was 4.1±1.1. In 11 (4.5%) patients conversion to open surgery was made due to intraoperative bleeding (3 cases) and technical difficulties (8 cases). Mean duration of postoperative pleural drainage and hospital-stay were 5.1±4.3 (median - 3 days) and 7.9±4.7 days (median - 6 days) respectively. Complications which were not associated with perioperative deaths were observed in 66 patients (26.8%). Prolonged air vent was the most common complication. CONCLUSION: VATS anatomical lung resections are safe and effective in most of pulmonary surgical diseases. Such interventions may be recommended for wider introduction at the Thoracic Departments of Russia because of small number of complications and rapid rehabilitation. Bleeding or its risk associated with fibrotic changes in pulmonary root are the most frequent causes of conversion to open access.

[Initial experience of thoracoscopic lobectomy performance with bronchoplasty].

The article presents an initial Russian experience of video- thoracoscopic bronchoplastic lobectomies performed in 2 clinical cases of centric lung tumors. The upper bronchoplastic lobec- tomies with right lymphodissection were carried out on two patients in 2012. Complications weren't observed in intraopera- tive and postoperative periods. There wasn't relapse during two years after operation. Thus, the authors came to conclusion that thoracoscopic bronchoplastic lobectomies turned out to be safe and effective interventions in individual patients with centric tumor location, which wasn't extended outside mouth of the lobar bronchus. The choice of candidates for thoracoscopic bron- choplasty was made using video-bronchoscopy, angio-computer tomography of the thorax and PET. This allowed avoiding an invasive staging and excluded patients with substantial extra- bronchial lesions.

[Technique of endarterectomy from pulmonary artery in chronic thromboembolic pulmonary hypertension].

The article gives detailed description of a technique of pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. The method is based on the experience of the world leader in surgical treatment of this disease--the clinic of California, San Diego headed by Stuart Jamieson, cardiothoracal clinic Papworth Hospital in the only center in Great Britain, where PE is performed and on the experience obtained by the collective of the Department of hospital surgery of the medical department of the St. Petersburg state University and the City multi-field hospital.

[The possibility and prognostic value of secondary lymphatic cancer spread in intrapulmonic metastases of solid tumors].

In the period from 1996 to 2007 operations were fulfilled in 120 patients with isolated pulmonary metastases of solid tumors (68 men and 52 women aged from 22 through 77 years): 46 patients with metastases of colorectal cancer, 28 - with cancer of the kidney, 23 - with non-small cell carcinoma of lung, 7 - with breast cancer, 9 - with endometrium cancer, 7 - with melanoma. Altogether there were 128 operations. The operations have revealed lesion of intrathoracic lymph nodes in 29 patients (24%). In most cases (21 patients) they were lesions of lymph nodes of the lung root and intrapulmonary lymph nodes. In 93% of cases (27 patients) localization of the lesion coincided with anatomical pathways of lymph outflow from the affected part of the lung. The survival rate median of the operated patients who had alterations in the lymph nodes was 21 months, in cases with intact lymphatic system it was 37 months. A conclusion is made of possible secondary lymphatic cancer spread from intrapulmonary metastases of solid tumors and its negative influence on results of treatment that allows recommendation of revision of the lymphatic system of the lungs and mediastinum in all cases of surgical treatment of intrapulmonary metastases, and in a number of cases recommendation of anatomical resections of the lung tissue as operation of choice.

[The first successful bilateral lung transplantation in Russia].

Lung transplantation is one of the most difficult fields of contemporary transplantology. The operation was performed on a 53-year-old female who had been suffering from terminal stage COPD. The period of cold ischemia for the right and left lung was 1 hour 30 minutes and 2 hours 25 minutes respectively. The total operation time was 4 hours and 40 minutes. There were no surgical complications. There were no signs of transplant rejection 6 weeks after the operation. The considerable decrease in dispnea and increase in quality of life were registered during the follow-up. FEV1 was increased by 80% and 6 minute walk test distance was increased by 200 meters.

[Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas].

A retrospective matched-pair comparison was undertaken to evaluate the surgical and neurological outcomes after open and VATS thymectomy for patients with myasthenia gravis (MG) and thymoma. Ten women and seven men aged 14-77 years were operated upon in St. Petersburg Center of intensive pulmanology and thoracic surgery during the years 1995-2002. Results of two groups were compared: 1 - operated by VATS (9 patients) and 2 - operated via sterno- or thoracotomy (8 patients). The first step evaluated the distribution of age, gender, myasthenia severity, size, type of thymoma and Masaoka's stage. No difference between the groups was found. At the same time, the length of chest tube, blood loss, severity of postoperative pains were significantly lower in the first group as compared with the second one: 1.3+/-0.9 vs 6.2+/-4.5 days; 82.5+/-22.7 vs 557.1+/-212 ml; and 1.9+/-0.8 vs 6.1+/-1.2 points respectively. The number of postoperative complications was almost the same. All the patients were followed up during 24-96 months. There were no thymoma recurrences in the both groups. No statistical differences were found in MG course between the groups. A conclusion is made that VATS removing of noninvasive thymoma is technically feasible and safe for the patients. VATS thymectomy can provide the same results in MG treatment as the open approaches.

[A technique of videothoracoscopic thymectomy in diseases of the thymus].

Intensive development of thoracoscopic thymectomy (Tthy) has been initiated during the last decade. Unfortunately very few instances of using the procedures have been described in Russian medical literature. So, the paper describes in detail the technique and results obtained in our clinic. At the period from 1998 through 2004 37 Tthy operations were performed in the St. Petersburg Center of intensive pulmonology and thoracic surgery. There were 21 female and 15 male patients with mean age 41.5+/-18.9 years. Myasthenia gravis (MG) was diagnosed in 19 of those patients. Different thoracoscopic approaches were used for Tthy: 20 from the right side, 15 from the left side and 2 combined approaches with neck incision. In 2 cases when invasive thymoma was suspected, sternotomy had to be used. There were 6 postoperative complications (1 haemothorax and 5 myasthenia cases). One patient died in 45 days after operation because of the ventilation-associated pneumonia. The results of treatment were followed up in 34 patients during 6-34 months. The MG course was followed up in 17 out of 19 patients, 9 (52.9%) being asymptomatic, 6 (35.3%) improved and 2 (11.8%) stable. Tthy is a novel technical possibility for a removal of the thymus gland. The procedure is quite safe and radical in the hand of a surgeon experienced in mediastinal and thoracoscopic surgery. Treatment of thymoma using Tthy requires meticulous technique and longer follow-up.

[Diagnostic and treatment strategy for patients with the first episode of primary spontaneous pneumothorax].

A retrospective analysis of 198 patients (164 men and 28 women) with the first episode of primary spontaneous pneumothorax (PSP) was made. All the patients underwent diagnostic thoracoscopy (DT) under local anesthesia before insertion of a chest tube. For 115 patients the chest tube thoracoscopy was the only treatment procedure (group I) and 77 patients underwent video-assisted thoracoscopic (VATS) wedge (atypical) resection and pleurectomy (group II). The patients were followed-up from 13 through 77 months. In group I there were 19 recurrences (16.5%), and only two recurrences in group II. In patients of group II having no pathological changes there were no recurrences while in group I there were two (3.3%). The recurrence rate in patients with pathological changes (II, III and IV stages of Vanderschuren classification) was 3% after VATS and as high as 31.5% after the chest tube treatment. The diagnostic thoracoscopy should be performed in all patients with the first episode of PSP for the assessment of the lung and pleura condition. The presence of any pathological changes points to a high risk of recurrences and should be considered as an indication for antirelapse measures (VATS). Surgery is not necessary when no morphological alterations are revealed at DT.