Objective: Although widely adopted, there is lack of immediate and long-term follow-up data for patients undergoing video-assisted thoracoscopic surgery (VATS) management of pneumothorax. Therefore, ...we have reviewed our experience with both primary (PSP) and secondary (SSP) spontaneous pneumothorax to assess the perioperative outcomes and long-term efficacy associated with different VATS operative strategies. Methods: A retrospective case series review was undertaken on all patients undergoing VATS procedures for PSP or SSP over a 17-year period. Results: A total of 644 VATS pneumothorax procedures were performed between 1992 and 2008 on 569 patients, of which 550 procedures were performed for PSP and 94 for SSP. Mean age for PSP and SSP groups were 28.4 ± 10.4 and 58.2 ± 14.2 years, respectively. Surgical technique used bullectomy in combination with abrasion (273), poudrage (246) and pleurectomy (46). Isolated poudrage was used in 72 cases. Median postoperative stay was 3 and 4 days, respectively. Major complications occurred in 25 (4.6%) PSP and 18 (19.2%) SSP patients. Two patients in the SSP group died (2.1%). Median follow-up was 73 months. Freedom from further surgery for the two populations was PSP: 98.1% at 5 years (confidence interval (C.I.): 96.9-99.4) and 97.8% at 10 years (C.I.: 96.5-99.2); SSP: 96.1% at 5 years (C.I.: 91.5-1.006) and 96.1% at 10 years (C.I.: 91.5-1.006). Freedom from further operation at 10 years was independent of the pleurodesis technique employed: abrasion 96.4%, poudrage 98.9% and pleurectomy 97.5% (p = 0.22). Conclusions: VATS management of both PSP and SSP offers good short-term results and excellent long-term freedom from repeat surgery. In combination with bullectomy, results of abrasion and poudrage do not significantly differ from pleurectomy. We recommend abrasion for pleurodesis in young patients reserving poudrage for the elderly. Pleurectomy may not be necessary.
Endometriosis is characterized by endometrial-like glands and stroma outside the uterine cavity, affecting women of reproductive age. Thoracic endometriosis syndrome (TES) is an entity producing a ...range of clinical and radiological manifestations, including catamenial pneumothorax, haemothorax, haemoptysis, and pulmonary nodules within the thoracic cavity or on the diaphragm. TES symptoms are nonspecific, warranting a high degree of clinical suspicion. Management includes hormone replacement therapy, surgical management, or a combination of both. We present a case of a 37-year-old woman who presented with TES and unilateral diaphragmatic palsy, managed with robotic-assisted thoracoscopic surgery and hormone replacement.
Pulmonary sleeve resection is a technically challenging procedure entailing expertise to perform via a minimally invasive approach. Robotic thoracic surgery with its three-dimensional high-definition ...imaging and true depth perception enables clarity of anatomical structures and, in conjunction with its articulated instruments, provides greater dexterity compared with video-assisted thoracoscopic surgery, allowing complex manoeuvres in limited spaces. We present the case of a 22-year-old woman who presented with recurrent chest infections, dyspnoea on exertion, cough, loss of appetite and weight loss. On investigation, she was diagnosed with an endobronchial neuroendocrine tumour. She underwent a robotic-assisted left upper lobe sleeve lobectomy and mediastinal lymph node dissection. The patient made a good recovery with no perioperative or postoperative complications. This case serves as an educational tool and includes instructions for excellent results.
Nitric oxide (NO) is a selective pulmonary vasodilator especially in the presence of pulmonary artery hypertension. With right ventricle (RV) dysfunction, inhaled NO may increase RV ejection fraction ...and cardiac output. The main advantage of NO over intravenous therapy is its inability to decrease systemic pressure thereby maintaining the coronary perfusion pressure and the myocardial perfusion. In this case report, we discuss the use of NO in a routine thoracic surgery patient suffering with severe left ventricular dysfunction and a potential candidate for a very high cardiac risk.
Robotic-assisted thoracoscopic surgery (RATS) facilitates complex pulmonary segmentectomy which offers one-stage diagnostic and therapeutic management of small pulmonary nodules. We aimed to explore ...the potential advantages of a faster, simplified pathway and earlier diagnosis against the disadvantages of unnecessary morbidity in benign cases.
In an observational study, patients with small, solitary pulmonary nodules deemed suspicious of malignancy by a multidisciplinary team were offered surgery without a pre or intraoperative biopsy. We report our initial experience with RATS complex segmentectomy (using >1 parenchymal staple line) to preserve as much functioning lung tissue as possible.
Over a 4-year period, 245 RATS complex segmentectomies were performed; 140 right: 105 left. A median of 2 (1-4) segments was removed. There was no in-hospital mortality and no requirement for postoperative ventilation. Complications were reported in 63 (25.7%) cases, of which 36 (57.1%) were hospital-acquired pneumonia. A malignant diagnosis was found in 198 (81%) patients and a benign diagnosis in 47 (19%). The malignant diagnoses included: adenocarcinoma in 136, squamous carcinoma in 31 and carcinoid tumour in 15. The most frequent benign diagnosis was granulomatous inflammation in 18 cases.
RATS complex segmentectomy offers a precise, safe and effective one-stop therapeutic biopsy in incidental and screen-detected pulmonary nodules.
Higher capital costs and operating room costs associated with Lobectomy via Robot Assisted Thoracic Surgery (RATS) have previously been suggested as the principal contributors to the elevated overall ...cost. This study uses a micro-costing approach to a previous analysis of clinical outcomes of RATS, Video-Assisted Thoracic Surgery (VATS) and Open Lobectomy to evaluate the most significant cost drivers for the higher cost of robot-assisted lobectomy. A micro-costing model was developed to reflect the pathway of patients from day of surgery through the first 30 days following lobectomy. Costs were provided for RATS, VATS and Open approaches. Sensitivity analysis was performed specifically in the area of staff costs. A threshold sensitivity analysis of the overall cost components was also performed. Total cost per case for the RATS approach was €13,321 for the VATS approach €11,567, and for the Open approach €12,582. The overall cost differences were driven primarily by the elevated consumable costs associated with RATS Lobectomy. Capital costs account for a relatively small proportion of the per-case cost difference. This study presents a detailed analysis of the cost drivers for lobectomy, modelled for the three primary surgical approaches. We believe this is a useful tool for surgeons, hospital management, and service commissioning agencies to accurately and comprehensively determine where cost savings can be applied in their programme to improve the cost-effectiveness of RATS lobectomy.
A free, vascularized radial forearm fascia flap lined with two full-thickness buccal mucosa grafts can be used in cases of acquired, long-segment tracheal stenosis. To compensate for the absence of ...supportive tissue, the reconstructive tissue has to be supported by a stent for a period of 4 weeks. A case with an airway stenosis with a length greater than 5 cm is presented. The vascularized mucosa allowed for primary healing of the augmented airway. The tracheostomy could be closed shortly after stent removal.
Background. Tracheal obstruction secondary to benign proliferation of granulation tissue is a difficult problem to address if tracheal resection is contraindicated. Some patients may benefit from ...Nd:YAG (neodymium:yttritium-aluminum garnet) laser fulguration or tracheal stenting. If uncovered expandable metallic stents are employed granulation tissue can regrow and proliferate through the mesh, thereby obstructing the lumen once again. Covered metallic stents confer the advantage of preventing granulation tissue proliferation and therefore maintain patency of the tracheal lumen.
Methods. Two patients who developed tracheal obstruction secondary to proliferating granulation tissue formation after tracheostomy and who were medically unfit for prolonged general anesthesia were successfully treated using covered expandable metallic tracheal stents.
Results. Each patient demonstrated a significant improvement in respiratory status, and in both patients, at 6 and 9 months’ follow-up, stent position has not changed, tracheal lumen remains patent, and there has been no proliferation of granulation tissue through the stent.
Conclusions. Covered expandable metallic stents should be considered in the management of patients with proliferating tracheal granulation tissue when tracheal resection is contraindicated.
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