Video assisted thoracoscopic management of primary spontaneous pneumothorax

Although Video-Assisted Thoracoscopic Surgery (VATS) is now accepted by many as the approach of choice in the management of primary spontaneous pneumothorax (PSP), the optimal procedure and the timing of surgical intervention remain areas of contention. The authors reviewed their combined experience with 518 consecutive VATS procedures for PSP in 483 patients. Mechanical pleurodesis was performed in every case and was the only procedure in 20 patients. We had experience with several means of eliminating subpleural bullae once identified: stapled bullectomy (196), endoloop (261), argon beam coagulation (6) and endoscopic suturing (35). There were no mortality or intraoperative complications. Median postoperative hospital stay was 3 days. So far, we have had 9 recurrences (1.74%), after a mean follow up of 20 months (range one to 36 months). Complications consisted of 18 persistent air leaks, 14 would infections and 1 chest wall bleeding. We conclude that (1) VATS is a safe and effective approach in the treatment of PSP; (2) Stapled-bullectomy is quick and reliable but costly; (3) Endoloop and suturing are viable alternative techniques that may prove to be more cost effective; (4) we do not recommend to use argon beam coagulation as the primary treatment modality.

Thoracoscopic major lung resection--indications, technique, and early results: experience from two centers in Asia

The application of video-assisted thoracic surgery (VATS) to major lung resection is controversial. We reviewed our combined experience in this technique from two centers in Asia. From January 1993 to December 1995, 78 patients (44 male and 34 female patients with ages ranging from 16 to 85 years) successfully underwent VATS major lung resections. Selection criteria for this approach include (a) lesions < 5 cm in maximal diameter; (b) for primary lung carcinomas, clinical stage I status; (c) absence of chest wall involvement; (d) absence of pleural symphysis; and (e) complete or near complete interlobar fissures. Procedures included segmentectomy (1), lobectomy (69), bilobectomy (2), and pneumonectomy (6) together with mediastinal lymph node sampling in cases of primary malignancy. We emphasized not spreading ribs and using conventional thoracic instruments for dissection together with wound protection on specimen retrieval. There was one perioperative death and five nonfatal complications that included persistent air leak over 10 days in two patients, pneumonia in one, and persistent dysesthesia related to surgery in two. We conclude that VATS major lung resection is technically feasible. Stringent patient selection is important. Specific complications exist and special training is needed. The exact role of this approach in thoracic surgery remains to be defined by prospective randomized study compared with conventional thoracotomy with long-term follow-up.

Home-made endoloops for bullous lung disease: a case report

Various surgical techniques for bulla ablation have been used since the introduction of video-assisted thoracoscopic surgery. Endoscopic stapler resecting (Endo-GIA) is now the most common procedure for bulla ablation. Other endoscopic techniques include bulla suturing, clipping, laser ablation and electrocauterization. We present here a select report on using a "home-made" endoloop on a patient with bullous lung disease. No intraoperative morbidity was attributable to the procedure. The operating room time was 110 minutes, and ventilator support was given for 18 hours. The chest tube was removed on day 7 and the patient discharged on the ninth postoperative day uneventfully. The patient exhibited subjective improvement in his symptom preceptions during an one-month follow-up examination. A comparison of pre- and post operative functional evaluation showed increase in FEV1 (from 0.45 L to 1.02 L) during 3-month follow-up. From our experience, thoracoscopic home-made endoloop ligation is a safe and cost effective means of volume reduction surgery for bullous emphysema that interferes with optimum function of the adjacent lung parenchyma.

Technique of video-assisted thoracoscopic surgery for the spine: new approach

Although video-assisted thoracoscopy has only recently been applied to treat a variety of thoracic spine lesions, many problems and difficulties are encountered with this technique owing to limited trocar space and lack of suitable endoscopic instruments. Between November 1995 and March 1996, we practiced a new approach for video-assisted thoracoscopic surgery, the "extended manipulating channel method," for treating 18 patients with thoracic spinal lesions endoscopically. The thoracoscopic portals were made larger (usually 3-4 cm) and placed slightly more posterior than usual, which allows use of a combination of conventional spinal instruments and video-assisted thoracoscopy to enter the chest cavity and be manipulated similar to that with techniques used for standard open surgical procedures. In our series the endoscopic spinal procedures included biopsy only (n = 1), thoracic discectomy (n = 1), multilevel anterior discectomy and fusion (n = 1), corpectomy for decompression (n = 4), decompressions and interbody fusions (n = 10), and internal instrumentations (n = 4). Throughout the operation only one trocar was used for introducing the thoracoscope. There were no intraoperative deaths, and no patients showed neurologic deterioration due to the procedures. We conclude that such a technique makes thoracoscopy-assisted spinal surgery simpler and easier and has proved to be an effective, promising procedure. It does not appear to compromise the therapeutic goals set for the patients. The intraoperative vessel bleeding can be easily controlled, and the number of portals for the procedures can be reduced (on average, three portals are enough). Few endoscopic materials were used with our patients, and thus the total economic cost to the patients was reduced.

Localization of glutamate receptor subunits of the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) type in the pancreas of newborn guinea pigs

Glutamate and related molecules are the major excitatory neurotransmitters in the central nervous system, and their receptors have been localized therein. Little is, however, known about them in the peripheral nervous system. The present study investigated the localization of glutamate receptor subunits of the alpha-amino-3-hydroxy- 5-methyl-4-isoxazolepropionate (AMPA) type (GluR1, GluR2-3, and GluR4) in the pancreas of newborn guinea pigs. With a double-labeling method of immunofluorescence and immuno-tetrahydrochloride reaction, GluR1 and GluR4 immunoreactivities were localized mostly in the insulin-secreting cells in the central mass of the islet, and GluR2-3 immunoreactivity in the peripheral rim of the islet, which consists mainly of non-insulin-secreting islet cells. With a double-labeling method employing immunofluorescence and NADPH-diaphorase (NADPH-d) histochemistry, GluR2-3 and GluR4 immunoreactivities were localized in most of the NADPH-d positive pancreatic ganglion cells. None of the NADPH-d-positive ganglion cells showed GluR1 immunoreactivity. In fact, GluR1 immunoreactivity was not detected in any of the pancreatic ganglion cells. The results indicate that glutamate is likely to exert its effects on the pancreas by activating different AMPA receptor subunits located in endocrine cells and intrapancreatic ganglia.

Video-assisted thoracic surgery in treatment of chest trauma

Although the indications for video-assisted thoracic surgery (VATS) have expanded rapidly, especially in the areas of therapeutic and operative procedures, its role in the definite surgical treatment of chest trauma is not clear. From July 1994 to December 1995, 56 patients with hemothorax or posthemothorax complications resulting from chest trauma received thoracic surgery. Their ages ranged from 17 to 71 years. Mechanisms of injury included penetrating (n = 23) and blunt injury (n = 33). VATS was successfully applied in 50 patients; six patients with cardiovascular injuries (n = 4) or minor chest wall lacerations (n = 2) did not receive VATS. All patients who received VATS survived, with no morbidity. Twelve of the 50 patients treated with VATS would have otherwise had to undergo thoracotomy. Our results indicate that VATS can be safely used in hemodynamically stable patients with no cardiovascular or great vessel injury, sparing many patients the pain and morbidity associated with thoracotomy. Additionally, use of VATS may reduce the likelihood of posthemothorax complications by allowing early direct inspection of the chest wall, because VATS has a lower associated risk and can be performed with a lower index of suspicion than can standard thoracotomy.

Video-assisted coronary artery bypass grafting during hypothermic fibrillatory arrest

BACKGROUND

Hypothermic fibrillatory arrest without aortic cross-clamping is a technique for quieting the heart during coronary artery bypass grafting. This report reviews the preliminary results with this technique in 4 patients having video-assisted coronary artery bypass grafting.

METHODS

Four male patients 28.5 to 64.5 years old (mean age, 45.4 years) underwent operation for unstable angina. With video-assisted techniques, coronary artery bypass grafting was performed through a left anterior minithoracotomy with femoral-femoral cardiopulmonary bypass without cross-clamping the aorta. The myocardium was protected by continuous coronary perfusion during hypothermic fibrillatory arrest.

RESULTS

A left internal thoracic artery graft was anastomosed to the left anterior descending coronary artery in each patient. The posterior descending branch of the right coronary artery was grafted with a pedicled right gastroepiploic artery in 1 patient. The duration of cardiopulmonary bypass was 72 to 127 minutes (mean duration, 92 +/- 21 minutes). The postoperative course of each patient was uneventful. Follow-up (range, 3.9 to 5.8 months; mean follow-up, 4.9 months) was complete for all patients. There were no late deaths. Coronary angiography showed patent grafts. All patients were in New York Heart Association functional class I or II (mean class, 1.25).

CONCLUSIONS

Hypothermic fibrillatory arrest is a simple and effective method of quieting the heart, thereby providing a motionless operative field for video-assisted coronary artery bypass grafting.

Combination of high-dose chemotherapy, autologous bone marrow/peripheral blood stem cell transplantation, and thoracoscopic surgery in refractory nongestational choriocarcinoma of a 45XO/46XY female: a case report

A 39-year-old woman having a pure gonadal choriocarcinoma with lung metastasis was referred to our hospital after hysterectomy and bilateral salpingo-oophorectomy. She was found to have a 45XO/46XY karyotype and gonadal dysgenesis. The patient's serum beta-hCG was normalized after six courses of chemotherapy with cisplatin and etoposide of conventional dose (100 mg/m2, 100 mg/m2 x 3 days), but began to fluctuate. Thoracoscopic resection of a remaining pleural lesion was negative for malignancy. However, the disease relapsed as multiple metastatic nodules in bilateral lung fields and the mediastinum. After one course of priming chemotherapy with conventional dose (1 g/m2 cyclophosphamide, 400 mg/m2 carboplatin, and 500 mg/m2 etoposide), high-dose chemotherapy with a total dose of 1500 mg/m2 carboplatin, 1200 mg/m2 etoposide, and 5 g/m2 ifosfamide followed by autologous bone marrow transplantation and peripheral stem cell support was given. Thoracoscopic surgery was performed to resect two residual solitary metastatic lung lesions. With these salvage treatments, the patient obtained complete remission and remained disease free at last follow-up (17 months). Our result suggests that high-dose chemotherapy may be effective in chemosensitive nongestational choriocarcinoma when first chemotherapy has failed.

An alternative technique in the management of bullous emphysema. Thoracoscopic endoloop ligation of bullae

STUDY OBJECTIVES

With the improvements in video-assisted thoracoscopic surgery, more older patients and patients with respiratory impairments are undergoing bulla ablation using new and costly technology. We evaluated the cost-effective technique of thoracoscopic endoloop ligation of bullae in patients with bullous emphysema.

PATIENTS

From March 1992 through January 1996, 79 advanced age (mean age, 64 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Only patients with radiographically confirmed diagnosis of bullous emphysema were included in this evaluation. Thoracoscopic endoloop ligation of bulla was carried out under general anesthesia with double-lumen endotracheal tube and single-lung ventilation.

RESULTS

Sixty-five patients (82%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the Modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 6 days (range, 4 to 16 days). Average hospital stay was 9.5 days (range, 5 to 26 days). There was no postoperative death. A comparison of preoperative and postoperative functional evaluation was available in only 16 patients who showed an increase in FEV1 (from 0.85 to 1.02 L) and a decline in residual volume after operation. Complications include persistent airleak over 10 days in seven patients (8.9%), wound infection in three patients, and localized empyema in two patients. There was no recurrence after a mean follow-up of 21 months.

CONCLUSION

These encouraging results have shown that thoracoscopic endoloop ligation of bulla has proved to be a safe, reliable, and cost-effective technique for bullous emphysema. With careful preoperative evaluation and meticulous postoperative care, many patients could be rehabilitated by endoloop litigation of the bullae.

An ultrastructural study of the innervation of the guinea pig pancreas

The present ultrastructural study investigated the innervation of the guinea pig pancreas, with special emphasis on the pancreatic ganglia and the sympathetic and parasympathetic boutons/terminals. The pancreatic ganglion cells, ensheathed in a thin layer of connective tissue, showed typical features of autonomic neurons. Each contained a prominent eccentric round nucleus with 1 to 5 nucleoli and a copious cytoplasm with many organelles. Synapses were scattered in the ganglion and were of the axodendritic type. Axosomatic synapses were not encountered even after examination of semiserial sections in one of the tissue blocks. Desmosome-like junctions (puncta adhaerentia) were found between somata of the ganglion cells, and between their dendrites, and also between somata of the ganglion cells and satellite cells. The sympathetic nerves supplying the pancreas were demonstrated by the 5-hydroxydopamine loading method. Axon terminals loaded with the false transmitter were filled with intensely stained small dense-cored vesicles. These were present in close contact with acinar cells, islet cells as well as smooth muscle cells of arterioles. No 5-hydroxydopamine loaded axon terminals or ganglion cells were observed within the ganglia. The preganglionic parasympathetic nerve fibres supplying the pancreas traveling with the vagus nerve were studied by sectioning the left vagus nerve at mid-cervical level. Three to 7 days after left cervical vagotomy, degenerating axon terminals containing small spherical agranular vesicles, together with degenerating dendrites and neuronal somata showing electron dense cytoplasm were encountered within the pancreatic ganglion. The satellite cells were hypertrophied, showing a pale cytoplasm in which were embedded degenerating axon terminals and dendrites. In conclusion, the present study described the normal structure of pancreatic ganglia, provided ultrastructural evidence of the presence of sympathetic and parasympathetic fibres in the pancreas of the guinea pig, and reported postsynaptic changes in the dendrites after mid-cervical sectioning of the left vagus nerve.

Thoracoscopic loop ligation of parenchymal blebs and bullae: is it effective and safe?

Surgeons who have gained experience and confidence with video-assisted thoracic surgery are now routinely applying the minimally invasive approach to treat patients with spontaneous pneumothorax. Although the endoscopic stapling device may be a preferred method for resection of parenchymal blebs or bullae, the stapling device is not inexpensive. In an effort to contain costs since we started performing the video-assisted thoracoscopic procedure in chest surgical diseases, we have used a self-made endoscopic loop as an alternative method. It has assisted us in performing bulla ablation in a cost-effective manner. Over a 4-year period (1992 to 1996), we assessed the efficacy of ligating parenchymal blebs and bullae with a self-made endoscopic loop by video-assisted techniques. A total of 263 ligations were performed in 250 patients. Surgical indications included recurrence (n = 146), bilaterality of the disease (n = 13), hemopneumothorax (n = 7), radiologically demonstrated large bulla (n = 9), persistent air leak (n = 52), and nonexpansion of the lung (n = 23). There were no operative deaths. Early postoperative complications included a dislodged endoscopic loop necessitating reexploration in one patient and postoperative minor wound infections in 13. The average postoperative hospitalization was 4.5 days. Two hundred seventeen patients (86.8% of all patients) were followed up for a median of 28 months (1 to 46 months) after the operation. There have been no recurrences to date. Our results showed that thoracoscopic loop ligation is safe and effective in managing blebs and parenchymal bullae, with a lower cost, fewer complications, and a lower recurrence rate than provided by standard surgical techniques. On the basis of our results, we advocate the use of the self-made endoscopic loop for ligation of parenchymal blebs and bulla in patients with spontaneous pneumothorax to achieve a truly cost-effective and minimally invasive thoracoscopic procedure.

Video-assisted thoracoscopic operation for interruption of patent ductus arteriosus in adults

BACKGROUND

Patent ductus arteriosus (PDA) is a frequent congenital heart disease encountered in premature neonates, infants, and children. Video-assisted endoscopic techniques have been used in PDA interruption since 1993. Almost all the experiences are in pediatric patients. Applications in adults with PDA have been limited.

METHODS

We report our experience of video-assisted thoracoscopic surgical ligation of PDA in adults. From August 1995 to January 1996, 60 patients with PDA were operated on with a video-assisted thoracoscopic technique. Twelve adults were identified with mean age of 30 years (range, 20 to 57 years). With the patient under general anesthesia and double-lumen endotracheal intubation, two 5-mm holes were made in the left lateral chest wall. Another 4-cm incision was made in the left third intercostal space for manipulation, dissection, and ligation. Conventional surgical instruments were used except an endoscopic grasper and an endoscopic tube that connected to a video camera. The surgical procedure was viewed on a video screen. Transesophageal echocardiography was used for monitoring during PDA ligation.

RESULTS

All patients had successful ligation of the PDA. There was no surgical mortality, but there was one morbidity; transient recurrent nerve injury, which recovered 3 months later. Ten patients were extubated in operative room and 2 patients were extubated 2 hours after the operation. Tube thoracostomy was performed in the first 2 cases; it was omitted thereafter. No patients needed narcotic to control chest pain. Postoperative follow-up by echocardiography showed faint ductal flow in 1 patient without any murmur. All patients were discharged within 3 days after the operation.

CONCLUSIONS

Our experience suggests that with refinement of instruments and surgical technique, video-assisted thoracoscopic surgical ligation can be safely applied not only in pediatric patients, but also in adults with PDA.

Nitrergic neurons in the pancreas of newborn guinea pig: their distribution and colocalization with various neuropeptides and dopamine-beta-hydroxylase

The distribution of nitrergic neurons in the pancreas of the newborn guinea pig was first investigated, using nitric oxide synthase (NOS) immunofluorescence and nicotinamide adenine dinucleotide hydrogen phosphate-diaphorase (NADPH-d) histochemistry. There was total colocalization of NOS and NADPH-d in the pancreatic ganglion cells. NADPH-d was then used as a marker for NOS. In the whole mount preparation of the pancreas, most of the nitrergic neurons were located in the head and the body region, along the branches of pancreatic blood vessels. Some were also associated with the main pancreatic duct, islets of Langerhans and pancreatic acini. To investigate whether NADPH-d stained cells were neurons and whether NADPH-d was colocalized with various neuropeptides and dopamine-beta-hydroxylase (D beta H), an enzyme involved in the synthesis of noradrenaline, antibodies against neuron specific enolase (NSE), vasoactive intestinal peptide (VIP), neuropeptide Y (NPY). D beta H, substance P (SP), calcitonin gene-related peptide (CGRP) and bombesin (BOM) were used. Of all NSE positive ganglion cells, 76.8% were NADPH-d positive. NOS, VIP, NPY and D beta H immunoreactivities were found in both the neuronal cell bodies and nerve fibres in the pancreas while SP, CGRP and BOM immunoreactivities were detected only in the nerve fibres. SP-, CGRP- and BOM-containing nerves were in close contact with both NADPH-d positive as well as NADPH-d negative neurons. The percentages of NADPH-d/VIP, NADPH-d/NPY, NADPH-d/D beta H neurons in the total number of pancreatic neurons were 67.4%, 53.5%, 21.5% respectively. With double labelling in adjacent sections three subpopulations of pancreatic ganglion cells were demonstrated: NADPH-d/VIP/NPY, NADPH-d/VIP/D beta H and NADPH-d/NPY/D beta H.

Video-assisted cardiac surgery. Preliminary experience in reoperative mitral valve surgery

OBJECTIVES

Video-assisted endoscopic techniques had been applied in the surgical correction of patent ductus arteriosus, vascular ring, or coronary artery disease. However, it has been used only recently in the correction of reoperative mitral valve lesions.

DESIGN

Video-assisted cardiac operations were performed on four patients who had received surgical interventions on their mitral valves and needed emergent reoperation.

PATIENTS

Four patients (3 men and 1 woman) received emergency surgery from September to December 1995 for thrombosis of mechanical mitral prosthesis (2 patients) and severe mitral regurgitation with previously failed mitral valve repair (2 patients). Six previous operations had been performed on these mitral valves. Patient ages ranged from 26.7 to 68.1 years (mean, 47.3 years). Preoperatively, acute pulmonary edema occurred in two patients, cerebral emboli occurred in one patient, and sepsis was found in one patient. Mechanical ventilatory support was used in two patients before operation.

INTERVENTION

The operations were performed through right anterior minithoracotomy, guided by video-assisted endoscopic techniques with femoro-femoral extracorporeal circulation. The operative procedures were thrombectomy of mitral prosthesis in two patients, mitral valve repair in one patient, and mitral valve replacement in one patient.

RESULTS

The duration of extracorporeal circulation was 166 to 320 min (222 +/- 67 min) and the operation time was 4.6 to 6.8 h (6.1 +/- 1.0 h). All patients recovered from the operations rapidly with uneventful postoperative courses except 1 patient who had sepsis preoperatively and died 2 months later.

CONCLUSION

Our experience demonstrates that video-assisted cardiac surgery is technically feasible and could be performed in reoperation of the mitral valve.

Experimental patch bronchoplasty with ringed vascular graft

The best surgical technique in bronchial reconstruction is resection and end to end anastomosis, but in some cases either pathology length, reduction in tissue elasticity, or such circumstances, patch bronchoplasty may be necessary to reestablish air-passage continuity. The purpose of this experiment would thus try to investigate the possibility of using ringed polytetrafluoroethylene (PTFE) graft to repair the diseased bronchus. A 2 x 1 cm patch segment of bronchus resected in 10 dogs were followed up with monthly bronchoscopy and endoscopic photography. Euthanasia was performed at 3, 6 and 9 months or when signs of respiratory distress developed. At postmortem examination, the anastomoses were examined grossly and with light microscopy. In 5 of the 10 dogs that underwent bronchial repair with PTFE, granulation tissue developed at the anastomoses resulting in airway obstruction after 6 to 9 months. No epithelial growth occurred over the graft between the suture lines. We conclude that the granulation tissue formation at the anastomosis and the lack of respiratory epithelial ingrowth across the graft makes PTFE unsuitable for patch repair of the bronchial defect.

Video-assisted cardiac surgery in closure of atrial septal defect

BACKGROUND

Video-assisted endoscopy has been applied in the management of a variety of intrathoracic vascular lesions. Here we report its use in the correction of intracardiac congenital defects.

METHODS

Eight patients (3 male and 5 female) underwent operation for closure of an atrial septal defect. The patients ranged in age from 2.0 to 60.9 years (mean, 19.2 +/- 19.0 years). The patients weighed 11 to 66 kg (mean, 41.3 +/- 23.5 kg). The ratio of pulmonary blood flow to systemic blood flow ranged from 2.0 to 6.0 (mean, 3.4 +/- 1.3). The mean pulmonary artery pressure was 19.7 +/- 4.0 mm Hg (range, 13 to 24 mm Hg). The operations were performed through a right anterior minithoracotomy and guided by video-assisted endoscopic techniques under femorofemoral or femoral-right atrial extracorporeal circulation. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature, 22.0 degrees +/- 2.0 degrees C). Transesophageal echocardiographic monitoring was maintained during the operations. The right atrium was entered after pericardiotomy. Primary closure of the defect was performed successfully in all patients. Conventional nondisposable instruments were used for dissection, grasping, suturing, and hemostasis.

RESULTS

The durations of extracorporeal circulation and operation ranged from 47 to 126 minutes (mean, 80 +/- 31 minutes) and from 2.2 to 4.5 hours (mean, 3.1 +/- 0.8), respectively. All patients recovered from the operation rapidly with an uneventful postoperative course.

CONCLUSIONS

Our experience demonstrates that video-assisted cardiac surgery is technically feasible and can be used with excellent results for the repair of congenital heart defects in general.

Clinical challenge--an experience of spontaneous transmural rupture of the oesophagus in Taiwan

In Taiwan, spontaneous oesophageal rupture is uncommon but the outcome is often lethal because of failure to make an early diagnosis. We have analysed clinical data, management and the risk factors that affect mortality for a consecutive series of 11 patients who had spontaneous oesophageal perforation between 1983 and 1994. The primary symptom was chest or abdominal pain, which was present in 100% of patients; 91% of patients had abnormal chest x-ray (63% pleural effusion, 46% pneumomediastinum, 37% subcutaneous emphysema). In our series of patients the lower thoracic area was the most common location of the perforation (80% of patients. There were no statistically significant differences in mortality due to age, underlying disease, perforation size, location or surgical methods. A poor prognosis seems to be correlated with the time elapsed between the perforation and treatment (especially if > 72 hours) (p < 0.05), respiratory failure (p < 0.05), and heavy contamination of the mediastinum (p < 0.05). The clinical findings depend on the location and time of perforation. History, chest x-ray and oesophagogram are the most useful diagnostic tools. Early diagnosis and treatment are mandatory for these patients.

Video-assisted mitral valve operations

BACKGROUND

Video-assisted endoscopy has been applied frequently in the management of a variety of surgical diseases. However, it has rarely been applied in mitral valve surgery.

METHODS

We report 2 patients who received emergency operations for thrombosis of a mitral prosthesis (patient 1, a 68-year-old man) and acute mitral regurgitation due to rupture of anterior chordae (patient 2, a 75-year-old woman). They both had severe congestive heart failure. Cardiogenic shock was noted in patient 2. The mitral valve was approached through a right anterior minithoracotomy with the aid of an endoscope by means of projected images on the video monitor under femorofemoral cardiopulmonary bypass. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The left atrium was entered posterior to the interatrial groove. Thrombectomy and mitral valve repair were performed successfully.

RESULTS

The duration of extracorporeal circulation was 204 and 147 minutes, respectively. Both patients recovered from the operation rapidly with uneventful postoperative courses.

CONCLUSIONS

Our preliminary results suggest that video-assisted endoscopic cardiac surgery is technically feasible and could be performed in the milieu of open heart surgery.

Double-lumen endotracheal tube intubation in difficult intubation-use the WuScope System: a case report

Although not an absolute requirement in most cases, there are many anesthetic and surgical advantages for using a double-lumen tube during intrathoracic operations. It is almost impossible that double-lumen tube intubation by conventional methods in patients whose glottis can not be visualized by direct laryngoscopy. We describe the previously unreported method by using The WuScope System for double-lumen endotracheal tube intubation in a patient with acromegaly and difficult airway.

Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia

BACKGROUND

There have been few specific reports on negative outcomes after video-assisted thoracic surgery. We report our combined experience from two centers in Asia.

METHODS

From September 1992 to April 1995, 1,337 patients were operated on with the video-assisted thoracic surgical approach. All the patients were prospectively studied.

RESULTS

There was one death (mortality rate, 0.07%) and 56 nonfatal complications: persistent air leaks (21), bleeding (6), wound infection (13), empyema (2), cerebrovascular accident (1), reexpansion pulmonary edema (2), deep vein thrombosis (1), prolonged ventilatory support (4), intercostal neuralgia (5), and port-site recurrence (1), giving rise to an overall nonfatal complication rate of 4.26%. Procedure failures consisted of 7 recurrences of spontaneous pneumothorax (of 407 cases or 1.7%); 2 recurrences of malignant pleural effusion (of 39 cases or 5.1%), and 2 local recurrences after resections for stage I lung cancers (of 41 cases or 4.9%).

CONCLUSIONS

We conclude that video-assisted thoracic surgery is safe and effective for a wide range of procedures. A learning curve is present, and careful patient selection and attention to details are essential in optimizing surgical results.

Congenital tracheal stenosis: report of six cases

We experienced six cases of congenital tracheal stenosis during a 3 years' period from October 1991 to September 1994 in Chang Gung Children's Hospital, Taiwan. The presenting symptoms of congenital tracheal stenosis varied from acute obstructive upper respiratory episodes in young childhood, stridor and wheezing since birth, recurrent bronchiolitis, difficult to intubate with endotracheal tube. Although bronchoscopy was diagnostic, but further imaging studies without anesthesia were equivocal. In spite of pericardial patch-tracheoplasties, the two cases undergoing surgery expired. During follow-ups, the remaining four patients suffered from persisting noisy respiration by conservative management.

Video-assisted endoscopic esophagectomy with stapled intrathoracic esophagogastric anastomosis

Thoracic esophagus was usually removed through the transhiatal approach or via an open thoracotomy. The long incision and spreading of the ribs usually resulted in much pain and interference with chest wall mechanics. Today, with the development of a video-assisted endoscopic procedure, many intrathoracic lesions can be removed through small incision. Since March 1992 we have attempted 20 esophagectomies and reconstruction using a right thoracoscopic approach in 16 males and 4 females whose average age was 56 years. Indications for its use were esophageal cancer in 17 patients (squamous cell carcinoma in 12 patients, adenocarcinoma in 5) and caustic stenosis in 3. It is our impression that video-assisted endoscopic esophagectomy and reconstruction potentially causes less trauma, less postoperative discomfort, and a rapid functional recuperation. Our initial experiences showed that it is a feasible, effective procedure.

Thoracoscopic-assisted lobectomy. Preliminary experience and results

A preliminary report is made on the use of videothoracoscopy to achieve pulmonary lobectomy in 16 patients, including 12 with centrally located pulmonary metastases and 4 with benign lesions (3 bronchiectases and 1 endobronchial hamartoma). Videothoracoscopy was performed on eight right-lower lobes, one middle lobe, two right-upper lobes, four left-lower lobes, and one left-upper lobe with a thoracoscope and conventional thoracic instruments. All patients received standard pulmonary lobe resection with lymph node clearance similar to that achieved with open thoracotomy. The mean operative time was 3 h (range, 2.5 to 4 h). Average blood loss was 100 mL and mean length of hospital stay was 6 days (range, 4 to 8 days). A combination of videothoracoscopy with use of conventional instruments resulted in similar performance but less chest wall interruption than in conventional pulmonary lobectomy. Videothoracoscopy showed safer and faster lung resection, which subsequently minimized the perioperative morbidity. Pain intensity was lessened, functional recovery was quicker, and hospital stays were shorter in the patients we reviewed.

Thoracoscopic surgery as a routine procedure for spontaneous pneumothorax. Results from 82 patients

A total of 82 consecutive patients with recurrent or persistent spontaneous pneumothorax were considered for thoracoscopic blebectomy or bullectomy and pleurodesis. The median age was 47 years, and 70% were men. All the patients were successfully treated using a video-assisted thoracoscopic technique. There were no deaths attributable to the procedure. Complications occurred in 6 patients (7.3%). Three patients (4%) with diffuse bullous lung disease had prolonged intubation (9, 11, and 12 days, respectively). Persistent air leaks lasting from 10 to 14 days occurred in 2 patients (3%). One patient had an endoloop slip from the lung parenchyma after a forceful sneeze 2 days after the operation. Air leak subsided after the second operation using a conventional suturing technique. Blebs or bullae were present in 69 patients (83%). These were ablated by endoscopic stapling (37 patients) and through thoracoscopic ligation using an endoloop technique (32 patients). In this group of patients, the median postoperative hospital stay was 5 days. Thirteen patients with air leaks and diffuse bullous lung disease received only talc insufflation thoracoscopically. All of them showed good lung expansion after the operation. There are no recurrences, with a mean follow-up of 22 months. These results suggest that thoracoscopic ablation of blebs or bullae and pleurodesis may be applicable to patients with spontaneous pneumothorax who require surgical intervention.

Application of thoracoscopy for lung metastases

Lung nodules in patients with a history of malignancy usually require tissue diagnosis that will provide prognostic information and dictate further therapy. Patients with a favorable tumor histologic condition and limited tumor burden were often considered for resection. This is usually accomplished by wedge resection through open thoracotomy when the lesions were peripheral. However, complications related to open thoracotomy often exclude poor-risk patients, especially those with impaired pulmonary function. Currently, technique of thoracoscopic resection is opening up new vistas and unimagined options for the thoracic surgeon in the management of pulmonary diseases. With the application of thoracoscopy and small incisions, it is now possible for the thoracic cavity and its contained organs to be thoroughly explored. Our recent experience with the thoracoscopic resection as a primary treatment for lung metastases is the focus of this report. Forty-seven patients with a history of malignancy and new lung metastases underwent this type of resection. Postoperatively, there is less pain, quick functional recovery, and excellent cosmetic healing. It is a safe and promising approach.

Endothelium-dependent contraction of canine coronary artery is enhanced by crystalloid cardioplegic solution

Experiments were designed to determine whether hyperkalemic crystalloid cardioplegic solution enhances endothelium-dependent contraction of coronary arteries. Segments of canine coronary arteries (n = 8 in each group) were preserved in cold (4 degrees C) crystalloid cardioplegic solution (group 1) and physiologic solution (group 2) for 60 minutes. Segments of preserved and control (group 3) coronary arteries with or without endothelium were suspended in organ chambers to measure isometric force. Perfusate hypoxia (oxygen tension 35 +/- 5 mm Hg) caused endothelium-dependent contraction in the arteries of all three groups. However, vascular segments with endothelium of group 1 exhibited hypoxic contraction (68.5% +/- 15.3% of the initial tension contracted by prostaglandin F2 alpha 2 x 10(-6) mol/L, p < 0.05) that was significantly greater than contraction of the group 2 and group 3 segments with endothelium (26.6% +/- 5.6% and 20.6 +/- 4.4%). The hypoxic contraction in arteries of group 1 could be attenuated by NG-monomethyl-L-arginine, the blocker of endothelial cell synthesis of the nitric oxide from L-arginine. The action of NG-monomethyl-L-arginine could be reversed by L-arginine but not D-arginine. Thus after preservation with cardioplegic solution, augmented endothelium-dependent contraction, occurs by L-arginine-dependent pathway, would favor coronary vasospasm after cardiac operation.

Thoracoscopic management of effusive pericardial disease: indications and technique

Video-assisted thoracoscopic technique was evaluated in 28 patients who underwent operation for massive pericardial effusion. Excellent results were obtained using this newly developed approach for inspection of all pericardial surfaces as well as pleural and pulmonary disorders. No perioperative or postoperative complications ensued. Videothoracoscopy revealed positive lung malignancies in 11 patients, and these would not have been promptly diagnosed without thoracoscopy. Thoracoscopy also confirmed metastatic deposits on the pleura and diaphragm in 4 other patients. The visible nodules were proved to be metastatic adenocarcinoma. In 13 patients, thoracoscopy did not reveal malignancy, although 2 of these patients had a clinically suspected malignant lung tumor. Other indications for thoracoscopic drainage included 2 patients with impending pericardial tamponade after heart procedures and 6 patients with recurrent/loculated pericardial effusion. All of the patients showed promising and favorable postoperative courses after thoracoscopy. From our experience, video-assisted thoracoscopy was a safe and effective procedure, especially for those patients with combined pericardial effusion and abnormal pulmonary or pleural pathology in whom subxiphoid pericardial window was not clearly diagnostic at the time of operation. It was effective also in the situation with recurrent or loculated pericardial effusion which allowed localization and drainage of it. We believe that the use of videothoracoscopy to visualize the whole pericardial and pleural cavity will continue to be of great benefit to patients with combined pericardial and pleural/lung diseases.

Imaged thoracic resection of a huge mediastinal tumor--role of extended incision and the use of conventional instruments

Intrathoracic lesions are usually removed through conventional thoracotomy. The long incision and the spreading of the rib usually results in much pain and interference of chest wall mechanics. Today, with the development of imaged thoracic surgery (combination of thoracoscope and video optics), major procedures can be performed through small incisions. However, indications are greatly limited due to lack of suitable instrumentation and restricted space of the trocar channel especially when a huge intrathoracic tumor is encountered. In this selected report, we demonstrate a successful procedure using extended incision and conventional instruments in imaged resection of a huge cystic intrathoracic tumor. The procedure offers the benefit of safe, easy and fast manipulation. The patient had an uneventful postoperative course and was discharged on the fourth postoperative day.

Video-assisted thoracic surgery. The Chang Gung experience

Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as follows: (1) Video-assisted thoracic surgery can be as effective therapeutically as many formal thoracotomy. (2) Excellent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an excellent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visually guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also allows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest.

Localization of NADPH-diaphorase positive neurons in the pancreas of the mouse, rat, chick, kitten and monkey

In the present study, nicotinamide adenine dinucleotide hydrogen phosphate-diaphorase (NADPH-d) histochemistry has been used as a marker for nitric oxide synthase. NADPH-d positive neuronal cell bodies and fibres have been localized in the pancreas of the mouse, rat, chick, kitten and monkey. In all these species, most of the NADPH-d labelled neuronal cell bodies in the ganglia were found in the interlobular and interacinar connective tissue while some were intimately associated with pancreatic ducts and blood vessels. There was, however, a gradation of innervation amongst the species. Only in the pancreatic islets of the mouse and monkey were NADPH-d positive neuronal cell bodies and nerve fibres detected in the formation of neuro-insular complexes. Besides labelling of neuronal cell bodies, nerve fibres and endothelial cells, the islet cells of the mouse, kitten and chick pancreas also gave a light positive reaction for NADPH-d activity. The nerve fibre and the outer core of the connective tissue of the Pacinian corpuscles in the kitten pancreas were also labelled for NADPH-d activity. It is concluded that nitric oxide may play an important role in the neural regulation of both exocrine and endocrine secretion and in controlling the activity of the blood vessels and ducts of the pancreas.

Video-assisted thoracic surgery. Manipulation without trocar in 112 consecutive procedures

Since learning of the video-assisted thoracoscopic techniques in the treatment of thoracic diseases, we have encountered many problems and difficulties because of the limited trocar space and lack of suitable instrumentations. Since March 1992, we have found a simple and easier way to perform this procedure, that is, manipulating through the extended incisional wound without using a trocar. Endoscopic and conventional thoracic instruments are able to pass through the incisional channel freely and manipulate similarly to the technique used in open thoracotomy. All the patients had less postoperative pain, reduced operative time, and prompt return to employment. The technique is effective and is herein described.

Thoracic actinomycosis

Actinomycotic infection is uncommon and primary actinomycosis of the lung and chest wall has been less frequently reported. This disease may present as chronic debilitating illness with radiographic manifestation simulating lung tumor, pulmonary infiltrating lesion, or chronic suppuration. From 1984 to 1990, we experienced 17 cases of thoracic actinomycosis. There were nine patients who presented with a clinical picture of a suppurative lesions and the remaining eight were suspected of having primary lung tumor initially. In no case was an accurate diagnosis made at the time of hospital admission. Final diagnosis was based on aspiration (n = 3), anaerobic sputum culture (n = 1), bronchoscopic biopsy specimens (n = 4), and histologic examination of the resected tissue in the remaining 9 patients who received surgical excision. Among the 17 patients, 8 were treated medically and the other 9 received surgical intervention followed by antibiotic treatment. Regarding the surgically treated patients, suspected malignancy is the most common indication for operation (seven of nine). However, both medically and surgically treated patients achieved good clinical results, and the postoperative courses were uneventful. We would like to remind physicians of this unusual entity and review our own experience with particular emphasis on the clinical diagnosis and management of this unique disease.

Gastro-pleural fistula related with penetrating stab injuries of the chest and abdomen: laparotomy or thoracotomy

A 30-year-old male presented with left side empyema due to gastro-pleural fistula following repair of penetrating stab injuries of left lower chest and abdomen. Exploratory thoracotomy was done due to persistent moderate amount of purulent discharge. However, fistula tract was not detected through this approach. The small fistula tract was repaired finally through laparotomy. We recommended the abdominal approach if the disease is not combined with diaphragmatic hernia. Transabdominal approach showed superiority in this rare entity.

Pulmonary artery perforation after Kirschner wire migration: case report and review of the literature

Utilization of Kirschner wires for bone and joint fixation is potentially complicated by migration of the wire from the fixation site over time. However, a review of the literature disclosed few reports of this complication. We describe such a case in order to emphasize the potential danger of the migration of such metallic devices used near thoracic cavity.

[Migration of Kirschner wire from the right sternoclavicular joint into the main pulmonary artery. A case report]

The use of Kirschner wires (K-wires) for bone and joint fixation carries the risk of migration of the wire from the fixation site over time. However, review of the literatures disclosed rather few reports on this issue. We describe such a case in order to emphasize the potential complication and serious hazard that migration of such metallic devices can result in, especially when the fixation site is close to the thoracic cavity.

Effect of dimethyl sulfoxide on cytosolic calcium in cultured rat hepatocytes injured by D-galactosamine

D-galactosamine (Gal 0.5 mmol.L-1) made lactate dehydrogenase (LDH) leakage from the hepatocytes in monolayer-culture increase by 50%, Dimethyl sulfoxide (Me2SO 2% vol/vol) decreased the LDH leakage (P less than 0.05). The cytosolic free Ca2+ concentration ([Ca2+]c) of rat hepatocytes exposed to Gal 4 mmol.L-1 for 90 min in suspension culture increased about 2-fold (P less than 0.01). Me2SO (2%) antagonized this [Ca2+]c-increasing effect of Gal. These results verified directly that the [Ca2+]c of hepatocytes was increased in the early stage of Gal-induced hepatotoxicity, and suggested that the prevention or lightening of the disturbance in intracellular Ca2+ homeostasis may be, at least, one of the mechanisms of the protective action of Me2SO against Gal-induced hepatocyte injury.

Endothelium-dependent production of prostacyclin in human internal mammary artery

The internal mammary artery (IMA) has become the conduit of choice in coronary artery bypass surgery because of superior long-term patency. It had been shown that IMA graft could release prostacyclin. Prostacyclin is a potent vasodilator and also can inhibit platelet aggregation. To determine the role of human IMA endothelium in production of prostacyclin, we tested the reactivity of segments of human IMA to hypoxia in vitro. Human IMAs were harvested during coronary artery bypass surgery. Prostacyclin was measured from fluid in the organ baths by radioimmunoassay of its major hydrolytic product 6-keto-prostaglandin F1 alpha. Rings (4 mm in length) of IMA, with and without endothelium, were suspended in organ baths containing physiologic salt solution. Rings were contracted with norepinephrine, and exposed to hypoxia (pO2 35 +/- 5 mmHg) for 15 minutes then reoxygenated. In segments with endothelium, hypoxia induced a transient relaxation followed by contraction. The transient relaxation was associated with a significantly increased production of 6-keto-prostaglandin-F1 alpha (from 34.1 +/- 2.7 pg/ml prehypoxia to 51.6 +/- 6.7 pg/ml during hypoxia, mean +/- SEM, p less than 0.05). This transient relaxation was blocked by indomethacin but not by NG-monomethyl-L-arginine (L-NMMA) and free radical scavengers (superoxide dismutase, catalase and deferoxamine). However, in segments without endothelium, the prehypoxia (14.7 +/- 0.9) and during hypoxia (15.5 +/- 1.4) level of 6-keto-prostaglandin F1 alpha were not increased and were significantly lower than those with endothelium. This study demonstrated that endothelium of IMA grafts could release prostacyclin either in a basal condition or upon stimulation of hypoxia. This ability possibly contributes to its long-term patency.

The threshold of survival for system of two species in a polluted environment

The effects of toxicants on naturally stable two-species communities are studied. Persistence-extinction thresholds are given for populations in the toxicant stressed Lotka-Volterra model of two interacting species. The threshold results are expressed in terms of relationships involving the population intrinsic growth rates, dose-response parameters, and interaction rates.

Disruption of the single tropomyosin gene in yeast results in the disappearance of actin cables from the cytoskeleton

The yeast tropomyosin gene, designated TPM1, is present in a single copy per haploid genome and encodes a protein with a predicted molecular weight of 23.5 kd. The protein sequence is homologous to higher cell tropomyosins, including the characteristic hydrophobic-hydrophilic pseudoheptapeptide repeats. Indirect immunofluorescence microscopy reveals that tropomyosin is localized with actin cables in wild-type cells. Disruption of TPM1 is not lethal, but results in a reduced growth rate and disappearance of actin cables. Strains carrying the conditional actin mutation act1-2 also lack actin cables; overexpression of tropomyosin in these strains partially restores actin cables. These results strongly suggest that tropomyosin interacts with F actin in vivo and may play an important role in assembling or stabilizing actin cables in yeast.

The application of leukocyte adherence inhibition assay to patients with colorectal cancer. Comparison with serum level of carcinoembryonic antigen and sialic acid

Antitumor immune response to colorectal cancer extracts was tested by leukocyte adherence inhibition (LAI) assay. Of 38 colorectal cancer patients, 26 (68.4 percent) were LAI positive. The sensitivity of LAI assay was found to be inversely related to the stage of the disease. In contrast, 2 of 50 (4 percent) healthy individuals, 2 of 37 (5.4 percent) patients with nonmalignant gastrointestinal diseases, and 2 of 32 (6.3 percent) patients with malignancies other than colorectal cancer were LAI positive. Serum carcinoembryonic antigen (CEA) and serum sialic acid (SA) also were determined in 38 colorectal cancer patients. Using LAI assay in combination with CEA determination could improve the detection rate of colorectal cancer.

Purification of tropomyosin from Saccharomyces cerevisiae and identification of related proteins in Schizosaccharomyces and Physarum

Tropomyosin is a key component of the contractile systems found in muscle and nonmuscle cells of higher eukaryotes. Based on properties common to all tropomyosins, we have purified a protein from Saccharomyces cerevisiae that resembles tropomyosins from higher cells. The yeast protein remains soluble after heat treatment at 90 degrees C, has an apparent polypeptide molecular weight of 33,000, an isoelectric point of 4.5, a Stokes radius of 3.5 nm, and a sedimentation coefficient of 2.6 S. It binds F-actin in a Mg2+-dependent, KCl-modulated manner, up to a stoichiometry of about 1 polypeptide per 3.0 actin monomers. In all these properties it is very similar to tropomyosins from higher cells. Antigen-affinity-purified antibodies specifically recognize the Mr 33,000 polypeptide among total yeast proteins and crossreact with bovine brain tropomyosin. In addition, the antibodies specifically crossreact with heat-stable Mr 33,000 polypeptides in extracts of Schizosaccharomyces pombe and Physarum polycephalum. Our detection of tropomyosin in lower eukaryotes suggests that they might have contractile systems very similar to those found in higher organisms.