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Eur J Cardiothorac Surg 1998;14:113-116
© 1998 Elsevier Science NL

Video-assisted thoracoscopic surgery: experience with 341 cases¹

Department of Chest Surgery, Heybeliada Chest Disease and Chest Surgery Center, Heybeliada, TR-81340 Istanbul, Turkey

Received 5 January 1998; received in revised form 28 April 1998; accepted 13 May 1998.

Corresponding author. Sofular yokusu, Taskin sokak No:11/4, 34031 Eyüp, Istanbul, Turkey. Tel.: +90 212 5655536/216 3518850, ext. 279; fax: +90 216 3511994; e–mail: heybeli@bnet.net.tr

	Abstract

Top Abstract Introduction Patients and methods Results Discussion References

 
Objective: Until recently, thoracoscopy had been used primarily for diagnostic purposes for more than 80 years in thoracic diseases. In this report we reviewed our video-assisted thoracoscopic surgery experience with 341 cases focusing on indications, operative procedures, complications or failure rates. Patients and methods: Over the last 3 years, we performed 459 video-assisted thoracoscopic procedures. There were 206 male and 135 female patients. Results: The indications were diagnostic in 171 cases, and therapeutic in 170 cases. There were no operative mortality. Non-fatal complications were seen in 15 cases (4.4%). The mean postoperative stay was 5 days. The specific procedures performed were operations on the pleura (237 cases), lung (158 cases), mediastinum (56 cases) and pericardium (four cases). Conversion to thoracotomy was needed in 43 cases (12.6%). Definitive diagnosis was obtained in 100% of patients with pulmonary nodule/mass or diffuse lung disease, and 95.2% of patients with undiagnosed pleural effusions. The success rate of thoracoscopic approach in non-tuberculous thoracic empyema was 87.3%. Conclusions: Video-assisted thoracoscopic surgery is an ideal procedure in the following situations: (1) undiagnosed pleural effusion, (2) recurrent pneumothorax or bullous lung disease, (3) stage II thoracic empyema, (4) lung cancer staging, (5) peripheral pulmonary nodule, and (6) wedge biopsy for diffuse lung disease.

Key Words: Surgery • Video-assisted thoracoscopic surgery (VATS) • Thoracoscopy

	Introduction

Top Abstract Introduction Patients and methods Results Discussion References

 
Since it was first described by Jacoboeaus in 1910, thoracoscopy has been used mainly for the diagnosis and limitedly for the treatment of pleural diseases [1]. The development of micro cameras and endoscopic equipment during the early 1980s, has expanded the application of minimal invasive surgery. Within a relatively short time, video-assisted thoracic surgery (VATS) has become a widely used technique for the treatment of many intrathoracic conditions [2] [3].

The present study reviews our experience with video-assisted thoracoscopic surgery in 341 patients in a teaching hospital. Indications, operative procedures, complications or failure rates in the context of modern thoracic surgical practice are discussed.

	Patients and methods

Top Abstract Introduction Patients and methods Results Discussion References

 
Between October 1993 and February 1997, 341 patients underwent various thoracoscopic interventions using video camera and endoscopic or standard surgical instruments. There were 206 men and 135 women with a mean age of 48 years (range 21–75 years).

General anesthesia with selective one-lung ventilation was used. Single dose third generation cephalesporin was given for prohylaxis in all cases. A 10-mm 0° rigid telescope and three ports approach were frequently used.

At the end of the procedure a 36 No. chest tube was placed at the lowermost insertion site. All patients were extubated immediately after surgery.

	Results

Top Abstract Introduction Patients and methods Results Discussion References

 
Indications for VATS were diagnostic in 171 patients, and therapeutic in 170 (Table 1). Four hundred and fifty-nine procedures were performed. Conversion to thoracotomy were in 12.6% (43/341) of patients. Chronic pleuritis requiring decortication was the most common indication of conversion (Table 2). There was no operative mortality. The overall median duration of chest tube drainage was 4 days (range 1–35 days), and median postoperative hospital stay was 5 days (range 2–45 days),except patients with thoracic empyema.

Preoperative intrathoracic staging and intrapleural lavage was performed in 47 and 38 patients, respectively. Excluding left paratracheal region, all lymph node stations of ipsilateral mediastinal were evaluated. Metastatic lymph node with pericapsular spread was found in four patients. T status was investigated in 13 patients, and three of these were found to be T4. Thus, unnecessary thoracotomy was avoided in seven patients. Preoperative pleural lavage was positive for malignant cells in 10.5% (4/38) of the patients.

Thoracoscopic wedge resection or forceps biopsy was performed in 50 patients with undiagnosed peripheral pulmonary mass, multiple pulmonary nodules, or diffuse lung disease. Wedge resection was done with electrocautery in 28 patients, and endoscopic stapling device in 22 patients. Postoperative period was uneventful in all patients. Definite diagnosis was obtained in all patients. There was no major complication requiring additional surgical intervention. Prolonged air leak (more than seven days) was seen in only one patient.

Forceps biopsy was performed on nine patients who had enlarged lymph node. The histological diagnosis was non-Hodgkin lymphoma in four cases, tuberculous lymphadenitis in three, and metastasis of an extrathoracic malignancy in two.

Perioperative complication was encountered only in one patient of the diagnostic group (0.6%). Conversion rate to thoracotomy was 2.9% (5/171) in this group.

Therapeutic (complex procedure) group
Thoracoscopic debridement or decortication was performed in 45 patients with fibrinopurulent (stage II) non-tuberculous empyema. The success rate was 80.3% (45/56). Videothoracoscopic decortication was performed in only four patients. The chest tube was removed after 5–38 days with a median of 11 days. The success rate of thoracoscopic treatment as an initial approach was 87.3% (49/56).

Stapling wedge resection was done in 41 patients. Indications for wedge resection were solitary pulmonary nodules in 28 patients, and bulla in 13.

Apical pleurectomy together with bullectomy or bulla ablation was performed in 13 patients with bullous lung disease. Twelve patients who had recurrent or persistent primary pneumothorax underwent pleural abrasion.

Thirty of 40 patients with malignant pleural effusions had diffuse malignant mesothelioma, and 10 patients had metastatic tumors. In the 27 of these patients, extensive parietal pleurectomy was performed to obtain a pleural symphysis, and 11 patients underwent partial pleurectomy and electrocoagulation. In two patients with trapped lung only biopsy was performed. The mean chest tube drainage time was 4 days (range 2–9 days), and total blood loss ranged between 400 and 700 ml.

There were 11 patients with late hemothorax. All of these patients had homogenous density in their chest X-ray after tube thoracostomy. Hematoma was evacuated, and fibrinous debris was completely removed.

Seventeen patients with mediastinal mass or cystic lesion underwent VATS. Three cystic hygromas in middle mediastinum, one mediastinal hydatid cyst in the left superior mediastinum, one metastatic melanoma, one timoma and two teratomas in the anterior mediastinum were removed completely.

The conversion rate to thoracotomy was 22.4% (38/170) in the therapeutic group, and postoperative complication rate was 8.2% (14/170). Postoperative complication occurred most commonly in patients with bullous lung disease (38.5%) and malignant pleural effusion (10%).

Overall, non-fatal complication rate of VATS was 4.4%. Prolonged air leak was the most common postoperative complication. Tumor implantation was observed in the port site within 6 months postoperatively in two patients with malignant pleural mesothelioma (Table 3).

	Discussion

Top Abstract Introduction Patients and methods Results Discussion References

The patients who had presumptive tuberculous pleurisy and persistent effusion after 2 months of antituberculous therapy were referred to our clinic for definite diagnosis. In the thoracoscopic evaluation, trapped lung was observed in 22 of these patients, and open decortication was added to the procedure. The diagnostic yield for thoracoscopy in undiagnosed pleural effusion was 95.2%. In only five patients which copious fibrinous debris over the pleural surface, superficial biopsies were insufficient for diagnosis. On the other hand, in 204 diagnostic thoracoscopies, the correct diagnostic rate was 97.5% (199/204) similar to the recent series [5] [6].

The recent development of video-assisted thoracic surgery has changed the surgical approach to patients with thoracic empyema [7] [8] [9] [10]. Thoracoscopic examination yields a detailed anatomic information about the stage, and extent of the empyema cavity that management guide the plan. Debridement of the loculation and fibrinous debris in the cavity allows us to re-establish the single pleural cavity, and chest tube placement carefully under a direct vision. This procedure can be described as an excessive debridement (not a decortication), unless the parietal wall or visceral peel was removed completely. If a thickened parietal wall and visceral pleural peel were discovered, thoracoscopic decortication was done in a selected group of patients in our series.

The use of thoracoscopy in the extraanatomic wedge excisions of undiagnosed pulmonary nodules in patients who have a subpleurally located small nodule (<3 cm) is the best alternative method to thoracotomy or `the wait and watch' approach. Wedge excision was made in 20.6% (91/441) of our procedures. Fifty-six of 91 wedge resections were done for diagnosis and other 35 procedures for therapeutic purposes. Because wedge resection with an Endo GIA is not cost effective, we used electrocautery successfully in 28 patients to obtain a lung biopsy for diagnosis of diffuse lung disease. Among the patients with resected nodules, 47.8% (32/67) had benign disease.

The role of VATS in the curative resection of early stage lung cancer or metastatic lung disease remains controversial [11] [12]. We prefer to do a formal resection and systematic mediastinal lymph node dissection for curative purposes, instead of wedge or VATS lobectomy in a patient with primary lung cancer

The role of VATS in the staging of patients with otherwise operable lung cancer is valuable. Thoracoscopy should be the next step in the evaluation of pleural effusions, if thoracentesis does not prove that the pleural effusion is malignant [13]. Moreover, thoracoscopy is a reliable procedure for N2 or T4 disease. Additionally, perioperative pleural lavage may give an opinion for patient survival. If there are no other contraindications to surgical resection, then thoracoscopy should be performed at the time of surgical resection.

Malignant pleural effusion is a regional problem in a patient with extrathoracic metastatic disease or it may be due to primary pleural tumor such as diffuse malignant mesothelioma. Talc insuflation or other thoracoscopic options such as pleurectomy or coagulation of parietal pleural surface can be used to create pleural adhesions. We prefer to do an extensive parietal pleurectomy both for pleurodesis and as a cytoreductive surgery in the management of massive pleural effusion due to diffuse malignant mesothelioma, if there is a trapped lung that does not fully re-expand following fluid evacuation. In our cases no operative mortality was encountered. This was obviously related to the timing of the surgical operation. Currently, it is not advised for patients in whom other treatment modalities are tried [14].

The overall conversion rate from thoracoscopic technique to thoracotomy was 12.6%. In most cases, the indication was dense adhesions preventing a space to maneuver. The 4.4% morbidity rate within this heterogeneous group of thoracoscopic procedures in our series compares favorably with previous reports [15].

In conclusion, this review indicates that VATS can be easily performed with minimal morbidity for therapeutic purposes as a current approach of thoracic surgery. Our indications for VATS include: (1) undiagnosed pleural effusions, (2) recurrent or complicated spontaneous pneumothorax, (3) stage II thoracic empyema, (4) more accurate staging for lung cancer, (5) peripheral solitary pulmonary nodule less than 3 cm, and (6) closed lung biopsy for pulmonary infiltrate.

	Footnotes

 
Presented at the 4th European Conference on General Thoracic Surgery, Cordoba, Spain, October 24–26, 1996.

	References

Top Abstract Introduction Patients and methods Results Discussion References

 

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3. Kaiser L.R. Video-assisted thoracic surgery: current state of the art. Ann Surg 1994;220:720-734.[Medline]
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5. Thomas P. Thoracoscopy: an old procedure revisited. In: Kittle C.F. editor. Current controversies in thoracic surgery. Philadelphia, PA: W.B. Saunders, 1986:101–106.
6. Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102:721-723.[Abstract]
7. Ridley P.D., Braimbridge M.V. Thoracoscopic debridement and pleural irrigation in the management of empyema thoracic. Ann Thorac Surg 1991;51:461-464.[Abstract]
8. Kern J.A., Rodgers B.M. Thoracoscopy in the management of empyema in children. J Pediatric Surg 1993;28:1128-1132.[Medline]
9. Strifteler H., Ris H.B., Wursten H.U., Hof V.I., Stirnemann P., Althaus U. Video-assisted thoracoscopic treatment of pleural empyema. A new therapeutic approach. Eur J Cardiothorac Surg 1994;8:585-588.[Abstract]
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11. Mc Kenna R.J. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. J Thorac Cardiovasc Surg 1994;107:879-882.[Abstract/Free Full Text]
12. Shennib H.A., Landreneau R.J., Nulder D.S., Mack M. Video-assisted thoracoscopic wedge resection of T1 lung cancer in high risk patients. Ann Surg 1993;218:555-560.[Medline]
13. Prokash U.B.S., Reiman H.M. Comparison of needle biopsy with cytological analysis for the evaluation of pleural effusion: analysis of 414 cases. Mayo Clin Proc 1985;60:158-166.[Medline]
14. Moghissi K. The malignant pleural effusion: tissue diagnosis and treatment. In: Deslauriers J, Lacquet LK, editors. Thoracic surgery: surgical management of pleural disease. St Louis, MO: Mosby, 1990:397–408.
15. Jancovici R., Lazdunski L.L., Pons F., Cador L., Dujon A., Dahan M., Azorin J. Complications of video-assisted thoracic surgery: a five years experience. Ann Thorac Surg 1996;61:533-537.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Muharrem Celik Semih Halezeroglu Canan Senol Senol Urek Hakan Kiral Bülent Arman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Celik, M. Articles by Arman, B. Search for Related Content PubMed PubMed Citation Articles by Celik, M. Articles by Arman, B.