Early removal of the chest tube after complete video-assisted thoracoscopic lobectomies.

OBJECTIVE: Chest tubes induce morbidity such as pain, decrease mobility, increase the risk of infection, and prolong the length of hospital stays. This study evaluates a chest-tube protocol containing a high-drainage threshold and a short time period of drainage. METHODS: A retrospective study was performed with data collected from all elective complete video-assisted thoracoscopic (c-VATS) (bi-)lobectomies between March 2006 and December 2009. All patients had one chest-tube, postoperatively. The chest tube was removed if there was no air leakage and there was a drainage volume of 400 ml (24 h)(-1) or less. We aimed to remove the chest tube on postoperative day 1. RESULTS: This series consists of 110 lobectomies and six bilobectomies. The median duration of chest-tube placement was 1.0 day. In 58.8% of patients (confidence interval (CI) 95%: 49.5-68.0), the drain was removed within 24 h of operation and in 82.5% (CI 95%: 74.2-88.7) within 48 h. In six (6.2%) patients, subcutaneous emphysema developed while the drain was still in place, and was treated with removal of the drain. Persistent air leakage was seen in four (3.4%) patients. One (0.9%) persisting pneumothorax was diagnosed. A pneumothorax after removal of the drain was not diagnosed. No major complications developed in 98 patients (84.5%). The median day of discharge was postoperative day 4. CONCLUSIONS: This study shows it is safe, after c-VATS (bi-)lobectomy, to remove the chest tube within 24 h in 58.8%, and within 48 h in 82.5% of patients. As was also shown in other studies, this leads to shorter length of hospital stays, lower costs, and most importantly, reduces patient morbidity without the added risk of complications.

The role of video-assisted thoracic surgery in the surgical treatment of superior sulcus tumors.

The surgical resection of sulcus superior tumors, also referred to as Pancoast tumors, remains a challenging surgical procedure. A patient presented with a superior sulcus tumor situated anterior in the thoracic inlet. The tumor was resected through a transmanubrial approach of Grunenwald combined with a video-assisted thoracic surgery (VATS) lobectomy. VATS can be very helpful in determining the exact location of the resection and at the same time performing a lobectomy avoiding extra morbidity due to a classical thoracotomy.

Complete video-assisted thoracoscopic surgery lobectomy and its learning curve. A single center study introducing the technique in The Netherlands.

Data regarding the benefits for the complete video-assisted thoracic surgery (c-VATS) lobectomy over the open lobectomy are numerous. This article describes the experience of introducing this technique in a training hospital, the first reported cohort in The Netherlands. From March 2006 to November 2008, all patients operated on for proven or suspected lung cancer were analyzed. Prospective data from these patients were evaluated. A subgroup analysis for the c-VATS lobectomy is presented. A total of 184 operations were performed on 172 patients. In 122 (66.3%) of the operations the resection ended in a lobectomy of which 70 were done by complete thoracoscopic procedure. For the c-VATS lobectomy the mean operating time was 179 min, with a mean blood loss of 444 ml. The median hospital stay was four days. Complications were present in 10% of c-VATS lobectomies. No mortality was seen in the c-VATS group. After thorough evaluation and training, c-VATS lobectomy is a safe procedure that can be performed in a relatively low volume hospital. It has exceptional short-term benefits. For training purposes all operations must start thoracoscopically. All patients must be operated according the intention to treat method.

Supervised exercise therapy for intermittent claudication in daily practice.

OBJECTIVE: This study describes the results and functioning of community-based supervised exercise therapy (SET) at one year of follow-up. METHODS: We conducted a prospective cohort study of community-based SET in regional physiotherapeutic practices. Consecutive patients with intermittent claudication referred for community-based SET were included. Exclusion criteria for SET were pain at rest or tissue loss. All patients received a diagnostic workup consisting of an ankle-brachial index at rest and after exercise. Interventions were exercise therapy according to the guidelines of the Royal Dutch Society for Physiotherapy. The primary outcome measurement was the increase in absolute claudication distance (ACD), assessed using a standardized treadmill protocol by a physiotherapist at baseline and at four, 12, 26, and 52 weeks of SET. RESULTS: From January 2005 through September 2006, 349 patients were referred by vascular surgeons for community-based SET. A total of 272 patients with intermittent claudication began the program. Of the 349 initially referred patients, 52 could not perform a standard treadmill test but did start community-based SET at a lower level, and 25 patients never started the program. At one year, 129 of the original 272 patients who began community-based SET (47.4%) were available for analysis of walking distance. In the interim, 143 patients discontinued the program for the following reasons: satisfaction with the acquired walking distance (n = 19); unsatisfying results (n = 26); not motivated (n = 22); (non)vascular intercurrent disease (n = 48); and other reasons (n = 28). ACD increased significantly from a median of 400 m at baseline to 1100 m after 12 months of follow-up (P < .001), corresponding to a median increase of 107.8%. CONCLUSION: Community-based SET seems as effective as SET in a hospital-based approach in improving walking distance, however, it has a high dropout rate.