Thoracotomy versus video-assisted thoracoscopic pleurectomy for spontaneous pneumothorax.

We reviewed our experience with thoracotomy (TH) and video-assisted thoracoscopic pleurectomy (VAT) for the treatment of recurrent spontaneous pneumothorax. Nine patients underwent 10 VATs. One patient had bilateral procedures 1 week apart. Nine patients underwent 10 THs. One patient had bilateral TH at the same session. The mean duration of postoperative hospital stay for VAT and TH was 5.7 days and 6.4, respectively. VAT operative time was longer (128 vs 93.6 min in the TH group); however, the estimated blood loss was larger in the TH group (136 vs 108.3 ml in the VAT group). There were no deaths in either group. In the VAT group, one patient had recurrence of pneumothorax 1 month after surgery. In the TH group, there was no recurrence of pneumothorax, but one patient had chronic pain at the site of the thoracotomy incision. One patient was lost to follow-up in each group. We conclude that VAT is a safe and reasonably effective treatment of spontaneous pneumothorax. However, large series with long-term follow-up are needed to place this procedure in its proper perspective.

Carotid and coronary arterial disease. A rational approach.

One hundred thirty-four patients referred for myocardial revascularization had oculoplethysmography/carotid phonoangiography (OPG/CPA) evaluations as a screening test for possible carotid arterial disease. On the basis of preoperative neurologic symptoms or hemodynamically positive OPG/CPA studies, 52 patients had carotid arteriography. Forty-six patients with coexistent carotid and coronary arterial occlusive disease were identified. Twenty-nine had a previous history of central nervous system (CNS) dysfunction, while ten patients (20%) were asymptomatic. Twenty-two patients had "staged" coronary artery bypass grafts (CABG) and carotid endarterectomy (CE) procedures, while 24 had simultaneous CABG/CE. Of the staged patients, one fatal myocardial infarction occurred after CE but prior to CABG; two patients experienced neurologic deficits after CABG yet prior to CE. Twenty-four patients had simultaneous CE/CABG, and no cardiac or neurologic complications occurred. All patients undergoing cardiovascular surgery should have preoperative noninvasive carotid screening studies performed. If OPG/CPA studies indicate a hemodynamically significant lesion, arteriography is indicated. When OPG/CPA studies are negative, yet a history consistent with previous CNS dysfunction is present, a digital intravenous arteriogram is performed. In the presence of coexistence severe coronary and extracranial carotid stenotic or ulcerative plaque disease, simultaneous CE/CABG is advocated.