Video-assisted thoracoscopic surgical thymectomy to treat early thymoma: a comparison with the conventional transsternal approach.

BACKGROUND: For thymoma, the feasibility of resection via video-assisted thoracoscopic surgery (VATS) remains controversial. The objective of our study was to compare the outcomes of VATS and transsternal thymectomy in order to evaluate the efficacy of the VATS method for treatment of early stage thymoma. METHODS: This study is a retrospective study of 120 patients who underwent thymectomy of early stage thymoma (Masaoka stage I and II) in a single medical center from 1991 to 2010. Of these patients, 76 patients underwent VATS thymectomy (VATS group) and 44 patients underwent the conventional transsternal approach (sternotomy group). We applied the Kaplan-Meier method to estimate overall survival (OS), recurrence-free survival (RFS), and time to tumor recurrence (TTR) of these two groups. RESULTS: The mean follow-up time was 61.9 months in the VATS group and 69.7 months in the sternotomy group. There was no surgery-related mortality or major complication. The VATS group had smaller specimen size (p < 0.05) and tumor size (p < 0.01), shorter length of stay (LOS) in the hospital (p < 0.01), and shorter duration of chest tube drainage (p < 0.05) than the sternotomy group. There were no significant differences between the two groups for OS, RFS, and TTR. CONCLUSIONS: In early stage thymoma, VATS thymectomy associated with shorter hospital LOS and shorter duration of pleural drainage compared with the conventional transsternal approach. Otherwise, the two approaches had similar oncologic outcomes during the mean 60-month follow-up period.

Thoracoscopic pleurodesis for primary spontaneous pneumothorax with high recurrence risk: a prospective randomized trial.

OBJECTIVE: To compare the efficacy and safety between apical pleurectomy and pleural abrasion with minocycline in primary spontaneous pneumothorax (PSP) with high recurrence risk. BACKGROUND: The optimal thoracoscopic pleurodesis procedure for PSP with high recurrence risk remains controversial. METHODS: Between January 2006 and May 2009, a total of 369 patients with spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. After stapled bullectomy, 160 patients with no identifiable bleb or multiple blebs (≥3) were randomly chosen to undergo apical pleurectomy (pleurectomy group, 80 patients) or pleural abrasion with minocycline (abrasion/minocycline group, 80 patients). RESULTS: Patients in the pleurectomy group had a longer operation duration (mean, 81.4 minutes vs 55.8 minutes, P < 0.001), a greater amount of operation bleeding (mean, 29.4 mL vs 13.2 mL, P = 0.025), and a greater amount of postoperative chest drainage (mean, 287.4 mL vs 195.8 mL, P = 0.040). Patients in the abrasion/minocycline group had a higher intensity of chest pain and required more frequent meperidine injections. Hemothorax occurred in 3 pleurectomy patients (3.8%). The short-term results showed that the 2 groups had comparable durations of postoperative chest drainage, durations of postoperative hospital stay, and complication rates. After a mean follow-up of 26.1 months, recurrent ipsilateral pneumothorax occurred in 3 patients (3.8%) in the pleurectomy group and 3 patients (3.8%) in the abrasion/minocycline group. Postoperative long-term residual chest pain and pulmonary function were comparable in both groups. CONCLUSIONS: : Pleural abrasion with minocycline pleurodesis is as effective as apical pleurectomy and either technique is appropriate for treating PSP patients with high recurrence risk. This trial was registered at http://www.clinicaltrials.gov (ID: NCT00270751).

18 years surgical experience with mediastinal mature teratoma.

BACKGROUND/PURPOSE: Few studies have examined the surgical outcomes of mediastinal mature teratoma in Taiwan. In the present study, the clinicopathological characteristics of mature teratoma and their impact on surgical outcome were analyzed. METHODS: From 1988 to 2005, 57 cases of mediastinal mature teratoma were reviewed. We collected and analyzed data about patient age, sex, symptoms, blood sugar, pulmonary function, diagnosis, tumor size, histopathological features, operative methods, operative time, tumor adhesion, blood loss, ventilator requirement, intensive care unit stay, chest tube requirement, and postoperative hospital stay. RESULTS: There were 18 male and 39 female patients with a median age of 27 years. Forty-three patients received conventional open surgery, whereas 14 received video-assisted thoracoscopic surgery. The patients in the thoracoscopic group had a decreased operative time (106.4 +/- 35.7 min vs. 205.4 +/- 75.7 min, p = 0.038), fewer ventilator days (0.2 +/- 0.4 vs. 0.5 +/- 0.8, p = 0.034), and a shorter stay in the intensive care unit (0.6 +/- 0.8 days vs. 1.5 +/- 1.4 days, p = 0.030). Pancreatic tissue was identified in 21 of 57 tumors (36.8%). The patients with tumors that contained pancreatic tissue had more presenting symptoms and complicated surgery than those whose tumors were without pancreatic tissue (76.2%vs. 33.3%, p = 0.002, and 42.9%vs. 11.1%, p = 0.008). The patients with symptoms had a higher incidence of complicated surgery than those without (39.3%vs. 6.9%, p = 0.004). CONCLUSION: Mediastinal mature teratoma commonly occurs in young women. Thoracoscopic surgery is a feasible technique for mediastinal mature teratoma resection if no dense adhesions are found during preoperative assessment. The presence of symptoms might be a relative contraindication for thoracoscopic teratoma resection because of its association with surgical complications.

Short-term outcomes of cadaveric lung transplantation in ventilator-dependent patients.

INTRODUCTION: Survival after cadaveric lung transplantation (LTx) in respiratory failure recipients who were already dependent on ventilation support prior to transplantation is poor, with a relatively high rate of surgical mortality and morbidity. In this study, we sought to describe the short-term outcomes of bilateral sequential LTx (BSLTx) under extracorporeal membrane oxygenation (ECMO) support in a consecutive series of preoperative respiratory failure patients. METHODS: Between July 2006 and July 2008, we performed BSLTx under venoarterious (VA) ECMO support in 10 respiratory failure patients with various lung diseases. Prior to transplantation, 6 patients depended on invasive mechanical ventilation support and the others (40%) needed noninvasive positive pressure ventilation to maintain adequate gas exchange. Their mean age was 40.9 years and the mean observation period was 16.4 months. RESULTS: Except for 1 ECMO circuit that had been set up in the intensive care unit for pulmonary crisis 5 days prior to transplantation, most ECMO (90%) circuits were set up in the operating theater prior to pneumonectomy of native lung during transplantation. Patients were successfully weaned off ECMO circuits immediately after transplantation in 8 cases, and within 1 day (1/10 patients) and after 9 days (1/10 patients) due to severe reperfusion lung edema following transplantation. The mean duration of ECMO support in those successfully weaned off in the operating theater (n = 8) was 7.8 hours. The average duration of intensive care unit stay (n = 10) was 43.1 days (range, 35 to 162 days) and hospital stay (n = 10) was 70 days (range, 20 to 86 days). Although 4 patients (40%) had different degrees of complicated postoperative courses unrelated to ECMO, all patients were discharged home postoperatively. The mean forced vital capacity and the forced expiratory volume in 1 second both increased significantly postoperatively. The cumulative survival rates at 3 months and at 12 months post-transplantation were 100% and 90%. CONCLUSIONS: Although BSLTx in this critical population has varied surgical complications and prolonged length of postoperative ICU and hospital stays, all the patients observed in this study could tolerate the transplant procedures under VA ECMO support with promising pulmonary function and satisfactory short-term outcome.

Cystic malignant teratoma with early recurrence after intraoperative spillage.

Teratoma with malignant transformation, defined as germ cell tumors with a malignant component of nongerm cell tumors, such as sarcomas and carcinomas, is rarely seen in the mediastinum. A rare case of the mediastinal mature cystic teratoma with focal gastrointestinal adenocarcinoma is described in this report. The patient underwent a video-assisted thoracoscopic surgery for tumor resection. Intraoperatively, the cystic tumor was ruptured due to dense adhesion. The rapid tumor dissemination was postoperatively noted. Careful and complete resection with the cyst wall of the mediastinal mature cystic teratoma intact is necessary to avoid a risk of relapse from a potentially malignant component.

Neglected esophageal injury presenting with spontaneously shrunken retroesophageal pocket.

Cervical stab wounds with a thoracic-inlet esophageal injury are extremely rare. A 30-year-old man presented with dysphagia and stridor. He had attempted suicide by stabbing his neck with a screwdriver followed by jumping from a building 10 days previously, when a cervical tracheal injury was found and surgically repaired. Physical examination was unremarkable. Lateral cervical radiography revealed an air-fluid level within an extensive retropharyngeal pocket. Follow-up radiography showed that the retropharyngeal lesion had shrunk spontaneously. Contrast esophagography demonstrated an extravasation at the thoracic inlet. The patient underwent surgical exploration of the esophagus via a lower neck incision. A thoracic-inlet esophageal slit was found and primary repair was performed. He resumed oral intake uneventfully on the 8th postoperative day. This was a rare case of esophageal injury secondary to cervical stabbing wounds, presenting with delayed occurrence and spontaneously shrunken retroesophageal pocket. Esophageal perforation can be easily missed if tracheal lesion is found. Both bronchoscopy and esophagoscopy are mandatory. In patients highly suspected to have esophageal injury but with a negative esophagoscopy result, contrast esophagography is indicated and can decrease the incidence of false-negative results.

Bronchoscopic gluing for post-lung-transplant bronchopleural fistula.

A 44-year-old female patient diagnosed as pulmonary lymphangioleiomyomatosis with respiratory failure underwent bilateral sequential lung transplantation using an entire left lung and a post-lower-lobectomy right lung due to pneumonia. Persistent air leakage during cough was noted and bronchoscopy 12 days after transplantation demonstrated post-lobectomy bronchial stump dehiscence with a large bronchopleural fistula. We applied twice tissue glue instillation on the dehiscent bronchial stump through flexible bronchoscopy. The air leak improved and the patient was discharged 3 months after transplantation uneventfully. Two months after discharge, bronchoscopy showed complete healing of the dehiscent bronchial stump. Now, she lives independently without oxygen support.