Major thoracoscopic operations: pulmonary resection and mediastinal mass excision.

After the great success of laparoscopy in the field of abdominal surgery, the mini-invasive approach has opened interesting new possibilities in the field of thoracic surgery too. At present, in many centres, thoracoscopy is the surgical approach of choice for the treatment of recurrent pneumothorax, giant bullous lung disease, peripheral benign lesions. In very few centres a new phase is now starting, having the objective of verifying the validity of more complex thoracoscopic surgical operations. The authors describe their experience in performing major thoracoscopic operations such as excision of mediastinal masses and major pulmonary resections. The series includes 36 patients submitted to thoracoscopic excision of mediastinal masses and 113 patients submitted to video-thoracoscopic major pulmonary resections. Every kind of mediastinal lesion as well as every kind of major pulmonary resection was performed; the evidence of no intra-operative deaths confirms the possibility of a useful employment of the mini-invasive approach in this kind of surgery.

Videothoracoscopic staging and treatment of lung cancer.

Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Videothoracoscopic excision of mediastinal masses: indications and technique.

Mediastinal masses are generally excised through wide thoracotomies or median sternotomies. These lesions are often benign, usually asymptomatic, discovered incidentally, and relatively easy to resect. For these reasons, a minimally invasive approach is appropriate. Videothoracoscopy allows an optimal exploration of the pleural cavity and a panoramic view of the mass. Dissection is usually easy to perform, and the mass can be extracted from the thorax through a trocar incision or through a limited "utility thoracotomy." To avoid possible tumor seeding, the mass is inserted in a plastic bag before extraction. From September 1991 to January 30, 1994, 20 mediastinal masses (6 thymomas, 2 thymic cysts, 1 hyperplastic thymus, 1 fibrous tumor of the mediastinum, 2 pleuropericardial cysts, 2 thoracic teratomas, 2 large thoracic lipomas, 3 neurogenic tumors, and 1 bronchogenic cyst) were removed through such a minimally invasive approach. Eighteen patients had an uneventful postoperative course. Two patients hemorrhaged in the immediate postoperative period, and repeat thoracoscopy was done. In 1 patient, electrocoagulation of a bleeding intercostal artery controlled the hemorrhage. In the other, the source of bleeding could not be found, and removal of the clots and irrigation of the cavity stopped the hemorrhage. Further data and long-term follow-up are necessary, but videothoracoscopy offers a new, less invasive approach for the management of noninvasive mediastinal masses.

Tracheal sleeve pneumonectomy for bronchogenic carcinoma.

For a long time, primary tumors arising less than 2 cm distal to the carina have presented a contraindication to surgical excision. Tracheal sleeve pneumonectomy technique allows carinal resection and reconstruction but still carries considerable postoperative complications. From 1983 to 1992 we performed 27 right tracheal sleeve pneumonectomies and one left. Fourteen patients had N0 nodes, nine had N1, and five had N2. No anastomotic complications, either fistula or stenosis, were observed. Successful outcome depends on meticulous attention to surgical details and careful anaesthetic management with a new ventilation tube. One patient died on the twenty-second postoperative day from myocardial infarction. Complications included pneumonia (one), vocal cord paresis (two), and pleural empyema without bronchial fistula (one). Conservative treatment allowed complete recovery from all complications. There are seven patients alive at 4 years after operation and one at 5 years. Six patients have been disease-free for between 1 and 32 months. Two patients died free of disease at 13 and 42 months. Two patients died of mediastinal recurrence and 10 of distant metastases within 6 and 54 months.

Major videothoracoscopic pulmonary resections.

Major pulmonary resections are generally performed through long thoracotomies which cause important functional and cosmetic sequelae. The progress in videoendoscopic surgery has allowed the authors to perform 31 pulmonary resections (28 lobectomies, 1 segmentectomy and 2 pneumonectomies) by thoracoscopic approach. Seven patients had benign pulmonary disease, 3 patients had pulmonary metastases and 21 cases suffered from a primary lung cancer TNM stage I. In all cases of malignancy hilar lymphadenectomy was performed. No major postoperative complications were observed. Functional and cosmetic results were always excellent.

Major pulmonary resections: pneumonectomies and lobectomies.

We report on our experience in 20 patients who underwent major thoracoscopic pulmonary resections between October 1991 and November 1992. These consist of 2 left pneumonectomies, 17 lobectomies, and 1 segmentectomy. The indications were strictly limited to benign pulmonary diseases and stage I (TNM) primary lung cancer. A hilar lymphadenectomy was performed in all cases of malignancy. Our surgical technique is described. Our findings demonstrate the feasibility of performing major video-assisted thoracoscopic pulmonary resections, even though the definite role of this procedure in the management of lung cancer must still be defined.

Videothoracoscopic excision of a mediastinal thymoma.

The authors have applied the advances in optics, endotelevision monitoring, and instrumentation that have led to the development of videoendoscopic abdominal surgery to performing major excisional procedures in the thorax. A videothoracoscopic technique for the removal of a mediastinal thymoma is described. The procedure was done on a 24-year-old woman suffering from a benign lymphoepithelial thymoma of the mediastinum. The mediastinal mass was mobilized under videolaparoscopic guidance and extracted from the thorax through a small (4 cm) inframammary incision. The postoperative course was uneventful, and the patient experienced minimal postoperative pain. She was discharged on the 3rd postoperative day with excellent functional and cosmetic results and resumed normal activity 4 days later.

Videoendoscopic thoracic surgery.

Personal experience of 42 videothoracoscopic operations is reported. From September 91 to May 92 we performed 10 major lung resections (1 pneumonectomy, 8 lobectomies, 1 segmentectomy) 9 wedge lung resections, 4 excisions of pulmonary bullae, 12 pleurectomies with or without apicectomy, 6 excisions of mediastinal masses (3 thymomas, 2 mediastinal cysts, 1 thoracic disembryoma), 1 removal of esophageal leiomyoma. No major complications occurred. Except for one patient submitted to bullectomy with pleurectomy who required a second thoracoscopy due to postoperative bleeding, all patients had excellent p.o. course. We describe technical details employed in different videothoracoscopic operations and discuss personal results and principles of videothoracoscopic approach. Different fields of videoendoscopic chest surgery are examined. Present data seem to advocate videothoracoscopic treatment for many thoracic diseases and also for major lung resections, due to its minimal trauma and little functional impairment. Nevertheless this still remains avant-garde surgery. Further improvement in endoscopic instrumentation is necessary and may lead to future extensions of videothoracoscopic surgical possibilities.

Locally advanced lung cancer treatment: personal experience of 588 stage III operated on patients.

From 1967 to 1988, we operated on 1507 non-small cell lung cancer. Complete data concerning patients at stage III are available for 501 of them. In 73% of cases the histological type was epidermoid, in 22% it was adenocarcinoma and in 5% large cells anaplastic carcinoma. Explorative thoracotomy (E.T.) was performed in 45% of interventions whereas curative resections in 55%. Sixty-two percent of these patients underwent pneumonectomy and thirty-eight percent lobectomy. Exeresis interventions were performed in patients at stage III A in 86% of cases, whereas in patients at stage III B in 14% of cases. Five years survival rate for stage III non small cell lung cancer is 17% whereas in stage II is 33% and in stage I is 52%. The only valuable prognostic factor seems to be the size of parenchymal exeresis. Indeed, survival rate after lobectomy is 24% versus 13% after pneumonectomy. In our experience the different survival between tumours at stage III A and tumours at stage III B are not significant, when the unexpected intraoperative finding of marginal infiltration of mediastinal organ is still compatible with resection. Also the survival rates between the two histological types are not statistically significant.

[Clinical significance of cell kinetics in lung cancer]. / Significato clinico della cinetica cellulare nel cancro del polmone.

A series of 24 lung cancer cases was studied: 12 epidermoid carcinomas, 9 adenocarcinomas, 2 giant-cell carcinomas and 1 carcinoid. The patients were staged on the basis of the TNM classification system as 9 stage I, 5 stage II, 9 stage III and 1 stage IV. Using fresh tumour cell samples 2 cell cultures were prepared for each patient: one to identify the percentage of S phase cells (Labelling Index) using the tritiated thymidine method and one for cytogenetic analysis. A gentic map was obtained in 6 cases and revealed no specific numerical or structural alterations. The Labelling Index (L.I.) was calculated for all patients and compared with all TNM parameters. This revealed a certain connection between L.I. and parameters T, SN and G but no link with parameters.