Video-assisted thoracic surgery lobectomy versus lobectomy by thoracotomy for lung cancer: pilot study.

OBJECTIVE: Video-assisted thoracic surgery lobectomy (VATS-L) has become accepted as a safe and effective procedure to treat early-stage non-small cell lung carcinoma (NSCLC). However, the advantages of VATS-L compared with lobectomy by thoracotomy (TL) remain controversial. The aim of this study was to compare the outcomes of patients who underwent VATS-L with those who underwent TL. METHODS: We studied 103 patients who underwent surgery for operable NSCLC between October 2009 and March 2012. All operations were performed by a single surgeon. The inclusion and exclusion criteria for VATS-L and TL were formulated before the study was initiated. Data on age, sex, preoperative comorbidities, intraoperative and postoperative complications, hospital stay, morbidity, mortality, and other characteristics were recorded preoperatively, in real time intraoperatively, and during hospitalization and were statistically compared. Comorbidities were scaled according to the Charlson Comorbidity Index, and propensity scores between the patients who underwent TL and VATS-L were compared. RESULTS: Sixty-three VATS-L operations and 40 TL operations were performed. There were no postoperative complications in 39 patients (61.9%) who underwent VATS-L compared with 25 patients (62.5%) who underwent TL. The patients who underwent TL were significantly younger than the patients who underwent VATS-L (mean ± SD, 64.7 ± 12.6 vs 70.9 ± 8.4; P = 0.003). Hospital stay was not found to be related to the type of surgery (mean ± SD, 8.43 ± 3.15 days vs 8.32 ± 4.13 days; P = 0.888). There were no significant differences when comparing postoperative complications. CONCLUSIONS: Our initial data suggest that VATS-L is a safe procedure in patients with resectable IA/IB NSCLC and may be the preferred strategy for treatment of the older patient population.

Endobronchial closure of recurrent bronchopleural and tracheopleural fistulae by two amplatzer devices.

We present a case of right pneumonectomy after induction chemotherapy complicated by a large bronchopleural fistula and empyema two weeks after surgery. The patient was treated surgically by transsternal transpericardial bronchopleural fistula closure and open window thoracoplasty. Thereafter, two new fistulae developed, one in the right main bronchial stump and one in the accessory tracheal bronchus. The two Amplatzer devices that were originally designed for transcatheter closure of cardiac defects were successfully used for closure of the bronchopleural fistulae.

Primary mucoepidermoid carcinoma of the trachea in a child.

Mucoepidermoid carcinoma of the trachea is a rare tumour, especially in the paediatric population. We report the case of a 9-year-old boy with mucoepidermoid carcinoma of the trachea that was preoperatively diagnosed as an intraluminal polypoid mass arising from the trachea and extending into the right main bronchus. A complete resection of the tumour with reconstruction and end-to-end anastomosis of the trachea was performed. The patient is now, 24 months after surgery, free of disease.

Lobectomy for non-small cell lung cancer: differences in morbidity and mortality between thoracotomy and thoracoscopy.

OBJECTIVE: Until the last decade, lobectomy by thoracotomy (TL) was the "gold standard" for treatment of patients with operable lung carcinoma. Today, video-assisted thoracic surgery lobectomy (VATS-L) has become accepted as a safe and effective procedure to treat early-stage lung cancer. We analyzed and compared postoperative complications, hospital stay, morbidity, and mortality after TL and VATS-L in patients with non-small cell lung carcinoma (NSCLC). METHODS: Between February 1998 and December 2007, we performed 326 TLs in patients with NSCLC. From December 2007, VATS-L was preferentially performed, and 63 cases of NSCLC patients underwent surgery using this method. Comorbidities were scaled according to the Charlson Comorbidity Index, and propensity scores between the TL and VATS-L patients were compared. RESULTS: Postoperative complications occurred in 142 TL patients (43.6%) and 17 VATS-L patients (27%), with 3.6% and 1.6% intrahospital mortality, respectively. There were no significant differences between the TL and VATS-L patients in Charlson Comorbidity Index or propensity scores, which led us to compare complications between TL and VATS-L groups and discovered that VATS-L patients had a shorter median length of stay (P < 0.001) and VATS-L was associated with a reduction in the occurrence of atrial fibrillation (P = 0.011) and offered benefits for patients with more significant comorbidities, for example, congestive heart failure patients (P = 0.042). CONCLUSIONS: Our clinical impression is that VATS-L offers advantages over TL in terms of lower morbidity, fewer and less serious complications, shorter hospital stays, and the possibility to operate on patients with more comorbidities.

Left ventricular epicardial lead implantation for resynchronisation therapy using a video-assisted thoracoscopic approach.

BACKGROUND: Cardiac resynchronisation therapy using a branch of the coronary sinus is the technique of choice for left ventricular (LV) pacing in patients with poor LV function. An alternative option is the surgical implantation of an epicardial LV lead under direct vision. We describe our initial experience with epicardial LV lead implantation. METHODS: The records of 10 patients undergoing epicardial LV lead implantation at our institution were retrospectively reviewed. Epicardial leads were implanted on the LV free wall using video-assisted thoracoscopic surgery techniques. RESULTS: Ten patients (seven men; three women; mean age 66.9 years) underwent surgery. All 10 patients suffered from congestive heart failure (CHF) and had a mean LV ejection fraction of 25%. All patients failed endocardial LV lead implantation via the coronary sinus because of lack of adequate branches or inability to cannulate the coronary sinus. There were no intraoperative complications, intrahospital or late deaths. The mean hospital stay was 5.2 days. Follow-up showed reversal of ventricular asynchrony and improvement in functional class in all patients. CONCLUSIONS: Thoracoscopic epicardial LV lead implantation is a safe and feasible procedure in a population of high risk patients who need resynchronisation therapy after endocardial LV lead placement has failed.

Thoracic empyema in high-risk patients: conservative management or surgery?

We retrospectively analyzed the data of 119 patients who were treated for empyema thoracis from 1999 to 2007. There were 87 men with a mean age of 63.9 years (range, 19-79 years) and 32 women with a mean age 55.2 years (range, 26-78 years). The empyema was right-sided in 73 patients and left-sided in 46. The etiology was parapneumonic in 43.7% of cases, postoperative in 42.0%, posttraumatic in 11.8%, and due to other causes in 2.5%. Eight (6.7%) patients underwent surgery on admission because of unstable clinical status; all 8 survived. Fibrinolysis was used in 111 (93.3%) patients; of these, 88 (73.9%) were successfully treated by intrapleural urokinase instillation, and 23 (19.4%) failed treatment and underwent surgery. All 88 patients who had successful fibrinolytic therapy survived, they accounted for 1.8% of the morbidity. In the 23 patients who underwent surgery after failed treatment, there were 3 deaths, accounting for 2.7% overall mortality and 6.3% morbidity. Treating thoracic empyema in patients with significant comorbidities is challenging. Intrapleural urokinase administration might be beneficial in high-risk patients, but in those without significant comorbidities, early surgery may be considered.

Posterior thoracic esophagostomy as an esophageal sparing procedure.

A diverting (posterior) thoracic esophagostomy is a rare, but acceptable, surgical option in some cases. The goal is to save as much esophageal length as possible with a view to future reconstructive surgery. We herein report a 41-year-old woman, in whom a posterior thoracic esophagostomy was successfully created and used for reestablishing further physiological alimentary continuity in a second stage.

Two cases of an enormous single-lung metastasis from synovial sarcoma.

Synovial sarcoma constitutes 8% to 10% of all sarcomas, and most commonly it affects adults in the third to fifth decades of life. This malignancy usually involves the extremities, and although local control by curative resection and adjuvant irradiation has improved, metastases develop in 40% of patients, with lung involvement in the metastatic process in 90% of cases. A single metastasis to the lungs from synovial sarcoma is rare, and a case of a large, single metastasis is even rarer. Herein, we present two cases of patients with an enormous metastatic synovial sarcoma that were successfully removed surgically.

Cervical mediastinoscopic lymphadenectomy for accurate staging in lung cancer.

Accurate preoperative staging of the mediastinum is important in the treatment of non-small-cell lung cancer. Enlarged mediastinal lymph nodes on chest computed tomography are positive for malignancy on mediastinoscopy in only half of these patients. After negative mediastinoscopy, some positive nodes are found at thoracotomy. The aim of this study was to attempt to remove all lymph nodes accessible by cervical mediastinoscopic lymphadenectomy and reevaluate the same mediastinal stations at thoracotomy for missed lymph nodes. Between 1999 and 2003, 30 patients with operable non-small-cell lung cancer and enlarged mediastinal lymph nodes (>1 cm in diameter on computed tomography) that were negative on cervical mediastinoscopy underwent pulmonary resection with complete lymph node dissection. The total number of lymph nodes dissected in these 30 patients was 329 (143 at mediastinoscopy and 186 at thoracotomy); the mean numbers of nodes dissected were 4.8 at mediastinoscopy and 6.2 at thoracotomy. Ten (6.5%) residual lymph nodes were detected at thoracotomy in mediastinal stations R4, L4, and 7. The low number of missed lymph nodes demonstrates the accuracy of the technique of cervical mediastinoscopic lymphadenectomy.

Large solitary fibrous tumour of the pleura: analysis of six cases.

BACKGROUND: A large solitary fibrous tumour of the pleura (SFTP) is a very rare occurrence. The aim of this study was to retrospectively review the clinical characteristics, surgical treatment and outcome of patients with a large SFTP operated on in our General Thoracic Surgery Unit. METHODS: We conducted a retrospective analysis of the clinical records of six patients who underwent surgery for a huge SFTP between 1998 and 2004. RESULTS: Six patients (four men and two women, mean age 73.3 years) with a large SFTP (mean diameter 20.3 and mean weight 1265 g) underwent surgery during this period with full excision of the tumour. Five tumours were excised together with the implantation basis, and in one case extended resection with pneumonectomy was performed. The presentation symptoms resolved in all cases after surgery. CONCLUSIONS: Despite the huge size of these tumours (giant SFTP), surgical resection is an acceptable method of treatment in elderly patients with low morbidity and mortality rates.