Video-assisted endoscopic esophagectomy with stapled intrathoracic esophagogastric anastomosis

Recent advances in thoracoscopic esophagectomy for esophageal cancer

Technical advances and developments in endoscopic equipment and thoracoscopic surgery have increased the popularity of minimally invasive esophagectomy (MIE). However, there is currently no established scientific evidence supporting the use of MIE as an alternative to open esophagectomy (OE). To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and we recently reported one of the largest propensity score-matched comparison studies between MIE and OE for esophageal cancer, based on a nationwide Japanese database. We found that, in general, MIE had a longer operative time and less blood loss than OE. Moreover, compared to OE, MIE was associated with a lower rate of pulmonary complications such as pneumonia, and both methods had similar mortality rates. Although MIE may reduce the occurrence of postoperative respiratory complications, MIE and OE seem to have comparable short-term outcomes. However, the oncological benefit to patients undergoing MIE remains to be scientifically proven, as no randomized controlled trials have been conducted to verify each method's impact on the long-term survival of cancer patients. An ongoing randomized phase III study (JCOG1409) is expected to determine the impact of each method with regard to short- and long-term outcomes.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Esophageal Cancer: Current Options for Therapeutic Management

BACKGROUND

Esophageal cancer (EC) is the eighth most common cancer worldwide. A worldwide-established consensus on therapeutic pathways for EC is still missing. Debate exists on whether neoadjuvant and adjuvant treatment regimens improve the prognosis and which surgical approach reaches objective benefits.

SUMMARY

This article discusses the appropriate option of the current different curative treatments in patients with EC, including surgical treatment and adjuvant therapy.

KEY MESSAGE

To maximize survival and quality of life and also decrease postoperative complications, the present recommended therapeutic management of EC should be individualized multidisciplinary team approaches according to patients' staging and physiologic reserve.

PRACTICAL IMPLICATIONS

The aim of this article is to provide a decision support and also a discussion based on clinical therapeutic strategy in order to characterize the beneficial approach which reaches an optimal balance between radical resection, postoperative outcome and long-term survival of EC.

Current status of minimally invasive esophagectomy for patients with esophageal cancer

Technical advancements and development of endoscopic equipment in thoracoscopic surgery have resulted in increase in the popularity of minimally invasive esophagectomy (MIE). However, advantages with regard to short-term outcome and oncological feasibility of MIE have not been adequately established. To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and the outcomes are comparable to those of conventional open esophagectomy (OE). A study group recently reported the results of the first multicenter randomized controlled trial (RCT) that compared MIE and OE. The incidence of pulmonary infection after surgery was markedly lower in the MIE group than in the OE group. Additional benefits of MIE included less operative blood loss, better postoperative patients' quality of life, and shorter hospital stay. However, the oncological benefit to patients undergoing MIE has not been scientifically proven because there have been no RCTs to verify the equivalency in long-term survival of patients undergoing MIE compared with that of patients undergoing OE. If future prospective studies indicate oncological benefits, MIE could truly become the standard care for patients with esophageal cancer.

Minimally invasive esophagectomy for esophageal cancer in the People's Republic of China: an overview

Since its introduction in the People's Republic of China in 1992, minimally invasive esophagectomy (MIE) has shown the classical advantages of minimally invasive surgery over its open counterpart. Like all pioneers of the technique, cardiothoracic surgeons in the People's Republic of China claim that MIE has a lower risk of pulmonary infection, faster recovery, a shorter hospital stay, and a more rapid return to daily activities than open esophagectomy, while offering the same functional and oncologic results. There has been burgeoning interest in MIE in the People's Republic of China since 1995. The last decade has witnessed nationwide growth in the application of MIE and yielded a significant amount of scientific data in support of its clinical merits and advantages. However, no prospective randomized controlled trials have actually investigated the benefits of MIE in the People's Republic of China. Here we review the current data and state of the art MIE treatment for esophageal cancer in the People's Republic of China.

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.

Video-assisted esophagectomy for esophageal cancer

Video-assisted surgery for esophageal cancer is an advanced surgical technique. It has been developed on the basis of the concept of minimally invasive surgery. Given that there are several options regarding the operative procedures for thoracic esophageal cancer, several laparoscopic approaches have been proposed. The first video-assisted thoracoscopic esophagectomy through a right thoracoscopic approach and the first transhiatal esophagectomy were reported in the early 1990s. A mediastinoscope-assisted esophagectomy has also been reported as a substitute for a blunt dissection of the esophagus. Moreover, a video-assisted Ivor-Lewis esophagectomy by right thoracotomy with intrathoracic anastomosis has also been performed. Furthermore, laparoscopic gastric mobilization and gastroplasty are also widely accepted substitutions for open laparotomy. This article reviews the literature on the laparoscopic approaches for esophageal cancer.

Minimally invasive esophagectomy: state of the art

Open esophagectomy is associated with significant mortality and morbidity, even in experienced centers. Two of the more frequent complications following esophagectomy are pneumonia and respiratory failure. Single-institution series have suggested that the incidence of these complications may be decreased with minimally invasive esophagectomy, with equivalent survival compared to open esophagectomy. However, this operation is technically challenging. In this review we detail the procedure as performed in our center, and also discuss some recent developments.

Minimally invasive techniques for oesophageal cancer surgery

Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of oesophagectomy since the early 1990s, including various combinations of thoracoscopy, laparoscopy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparotomy. The myriad of surgical approaches implies a lack of consensus on which is superior. Like open surgery, it is perhaps more important to have a tailored approach for the individual patient. MIS oesophagectomy has been shown to be feasible, and at least equivalent postoperative morbidity and mortality rates to open surgical resection have been demonstrated. Selected series have achieved less blood loss, reduction in some postoperative complications, decrease in intensive care and hospital stay, and better preservation of pulmonary function. Clear proof of superiority over conventional oesophagectomy methods however is not forthcoming since comparisons were often made with unmatched patient cohorts, and a well conducted randomized controlled trial has not been carried out. It is expected that with further improvements in instrumentation and experience, these difficult procedures may become more accessible and widely practised.

Minimally Invasive Esophagectomy for Stage I and II Esophageal Cancer

BACKGROUND

To evaluate whether thoracoscopic and video-assisted dissections are appropriate modalities, we assessed the mortality, morbidity, and survival of patients who underwent a thoracoscopic esophagectomy for esophageal cancer.

METHODS

Between November 1995 and December 2004, thoracoscopic and video-assisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%).

RESULTS

Intraoperative complications occurred in 4 (3.6%) patients: tracheal injury in 3 (2.7%) and azygos vein injury in 1 (0.8%). The 30-day mortality rate was 0.8%. Early postoperative complications occurred in 29 (25.9%) patients including the following: recurrent nerve palsy in 10 (8.9%), respiratory complication in 7 (6.3%), anastomotic leakage in 9 (8.0%) with major leakage requiring reanastomosis in 4 (3.6%) of these 9, and chylothorax in 3 (2.7%). Induction chemoradiotherapy, preoperative concomitant disease, and reconstruction using the colon did not increase morbidity. Port site recurrence occurred in 3 (2.7%) patients. The overall 5-year survival rate was 52%. For stage I disease, the 5-year survival rate of patients was 87.2%. In stage II disease, it was 70.2%.

CONCLUSIONS

Thoracoscopic and video-assisted esophagectomy are considered feasible and safe options for the treatment of esophageal cancer, but further investigation is necessary. The survival of patients with stage I and II disease is satisfactory at the present time.

Video-assisted Thoracoscopic Esophagectomy With a Voice-controlled Robot

The authors attempted to clarify the feasibility and safety of thoracoscopic esophagectomy with a voice-controlled robot, the AESOP system (3000 HR), and further determine whether innovative surgical equipment could allow the performance of complex thoracoscopic esophagectomy. Thoracoscopic surgery with a voice-controlled robot system has already been used in single-surgeon lung resection. Intra-operative and postoperative outcomes were compared between patients receiving hand-assisted laparoscopic surgery (HALS) and video-assisted thoracoscopic surgery (VATS) with the AESOP system (n = 15) and patients receiving open surgery (n = 30). In the AESOP group, the volume of blood loss was significantly less, but the total operation time was longer than in the open group. There were no significant differences in postoperative outcomes or the incidences of morbidity and mortality between the two groups. The surgeon using the AESOP system could obtain a stable, close-up, and long-lasting operative view. Laparoscopic and thoracoscopic surgery with the AESOP system has the potential to enable a single surgeon to perform a complex surgical procedure like esophagectomy.

New procedure for purse-string suture in thoracoscopic esophagectomy with intrathoracic anastomosis

BACKGROUND

In endoscopic surgery, one of the greatest problems is the difficulty with the reconstructive procedure. This problem frequently makes operating times longer. The authors have performed thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis for reconstruction using a circular stapler for the esophageal cancer. Although the circular stapler is a useful device for gastrointestinal anastomosis, it was difficult to place a purse-string suture and to fixate the anvil into the proximal esophagus endoscopically.

METHODS

The authors devised a new procedure for the placement of the purse-string suture by using an Endo-Stitch device along with a new method to incise the esophageal wall and thereby facilitate fixation of the anvil.

RESULTS

The authors attempted this procedure for five patients. The anastomoses were performed successfully.

CONCLUSIONS

The new procedure can make endoscopic intrathoracic anastomosis feasible and safe. In addition, this procedure can be applied widely to other endoscopic reconstructions.

Complications of minimally invasive esophagectomy

Esophagectomy is a complex procedure that is associated with significant morbidity and mortality in even the best of hands. With the introduction and widespread application of minimally invasive techniques, the possibility of improving outcomes has been entertained. In a series of 222 patients that underwent minimally invasive esophagectomy at the University of Pittsburgh, the mortality rate was 1.4%, with major morbidity occurring in 32%. The overall spectrum of complications encountered was similar to that previously reported in the largest open series. The marked reduction in mortality and hospital stay when compared with many open series may be an important consequence of the minimally invasive approach, though prospective randomized studies will be required to further assess this potential benefit.

Minimally invasive resection for esophageal cancer

MIE is technically demanding with a steep learning curve. Operative times decrease from 7 to 8 hours to 4.5 to 5 hours after the surgeons and assistants in the authors' center had performed 20 operations. In the authors' experience the operation was performed safely in the context of the authors' extensive experience with open esophageal surgery and advanced minimally invasive procedures. In the authors' first 77 cases, the 30-day operative mortality was zero, with a median hospital stay of 7 days, which compares favorably to many open series. Prospective studies will be required to determine whether postoperative pain, recovery time, and cost are improved. The optimal surgical approach for each patient should be decided based on surgical experience, tumor characteristics, and patient preference. A multi-institutional prospective trial is planned to evaluate the clinical and oncologic results of MIE for cancer compared with traditional open surgery.

Use of minimally invasive oesophagectomy for cancer of the oesophagus

Minimally invasive surgery has had a great effect on all branches of surgery, although its use for oesophageal cancer is controversial because of the technical complexity of the techniques involved and its uncertain benefits. We review the minimally invasive techniques that have been used for oesophagectomy. The methods are certainly feasible and can be done safely in experienced centres, but postoperative morbidity and mortality rates are not substantially reduced by the procedure. There are also concerns regarding the adequacy of tumour clearance. Further evaluation of the role of minimally invasive techniques in oesophageal cancer would require larger scale studies, preferably randomised controlled trials, in experienced centres. However, given that survival rates have not changed, proving that minimally invasive techniques are more effective than conventional methods of oesophagectomy, will be a difficult task.

Minimal access thoracic surgery for esophageal hemangioma

Esophageal hemangioma is a rare tumor. This report describes the case of a 69-year-old woman with an esophageal tumor at the middle portion of the esophagus. The patient was successfully treated with minimal access thoracic surgery, and at the 6 month follow-up, the patient was free of any symptoms or recurrence.

Thoracoscopic mobilization of the esophagus. A 6 year experience

BACKGROUND

Traditionally, esophageal resection has been performed using a thoracotomy to access the intrathoracic esophagus. With the aim to avoid the potential morbidity of the open thoracic approach, mobilization of the esophagus under direct vision recently has been described. We report our experience at attempting thoracoscopic mobilization of the esophagus in 162 patients during a 6-year period.

METHODS

Patients with malignancy or end-stage benign disease of the esophagus considered suitable for a three-stage esophagectomy underwent a thoracoscopy with a view to endoscopic mobilization of the esophagus. Of the 162 patients in whom the procedure was attempted, it was abandoned in 9 patients (6%), and the procedure was converted to open surgery in 11 patients (7%).

RESULTS

In the patients whose esophagus was mobilized, the average blood loss was 165 ml, and the average time for the thoracoscopic segment of the surgery was 104 min. In the 133 patients who underwent a resection for invasive malignancy, a limited mediastinal nodal dissection retrieved an average of 11 nodes, and the median survival was 29 months. The 30-day mortality was 3.3% and the in-hospital mortality 5.3%.

CONCLUSIONS

Thoracoscopic mobilization can be performed safely with satisfactory outcomes in a center performing a large volume of esophageal surgery and possessing advanced endoscopic surgery skills. Further assessment of this technique and comparisons with traditional open procedures are needed to assess this approach further as an appropriate oncologic procedure.

Esophageal cancer: a systematic review

Carcinoma of the esophagus has one of the lowest possibilities of cure, with 5-year survival rates estimated to be approximately 10% overall; these rates are second only to hepatobiliary and pancreatic cancers. This fact and the rapid increase in the incidence of adenocarcinomas of the esophagus in recent years challenges us to identify areas of improvement for all aspects of this disease. We discuss potential reasons for the increase in the incidence of adenocarcinomas, evidence that defines the similarity between tumors of the gastroesophageal junction and the tubular esophagus, and other prognostic factors that may influence future modifications of our staging classification of this disease. Surgical advances have translated into improvements in surgical morbidity and mortality rates. Current therapeutic options and the relative merits of the options are discussed. Improvements in patient outcome most likely hinge on earlier diagnosis, more accurate staging, and the optimal use of combined modalities, coupled with technical advances in the modalities. A systematic review approach was undertaken to evaluate the performance characteristics of newer staging tools and the value of different combined modality approaches with particular focus on the use of those approaches for patients with potentially curable disease. A similar methodologic approach was used to address the utility of the many strategies currently used in practice for the palliation of esophageal tumors, with particular focus on the relief of malignant dysphagia. Finally, a summary of published guidelines and population-based patterns of care are presented. This serves as an overview of how all of this evidence actually translates into the care we are providing. A coordinated international effort in population-based research and randomized controlled trials would be the cornerstone to future advances in this relatively uncommon but devastating disease.

Esophageal resection for cancer

Currently, relatively safe, reliable resection techniques are available for most patients with esophageal carcinoma who present with nonmetastatic disease. For optimal results, the surgeon must be familiar with both transhiatal and transthoracic approaches and must individualize the approach depending on the tumor size and location and the patient's functional status. Whereas post-resection survival rates are good for patients with early-stage disease (Stage I or IIa), most patients present with locally advanced, Stage III disease. Although some progress has been made in the past decade in regard to early diagnosis among patients with Barrett's metaplasia undergoing endoscopic surveillance and additional progress has been made in adapting multimodality treatment programs successfully to patients with locally advanced disease, the overall cure rate for patients with esophageal carcinoma remains low.

Esophagectomy for carcinoma of the esophagus in the elderly: results of current surgical management

OBJECTIVE

This study aims to evaluate the risk of esophagectomy in the elderly compared with younger patients and to determine whether results of esophagectomy in the elderly have improved in recent years.

SUMMARY BACKGROUND DATA

An increased life expectancy has led to more elderly patients presenting with carcinoma of the esophagus in recent years. Esophagectomy for carcinoma of the esophagus is associated with significant morbidity and mortality, and advanced age is often considered a relative contraindication to esophagectomy despite advances in modern surgical practice.

METHODS

The perioperative outcome and long-term survival of 167 elderly patients (70 years or more) with esophagectomy for carcinoma of the esophagus were compared with findings in 570 younger patients with esophagectomy in the period 1982 to 1996. Changes in perioperative outcome and survival between 1982 to 1989 and 1990 to 1996 were separately analyzed.

RESULTS

The resection rate in the elderly was 48% (167/345), lower than the 65% (570/874) resection rate in younger patients (p < 0.001). There were significantly more preoperative risk factors and postoperative medical complications in the elderly, but no significant differences were observed in surgical complications. The 30-day mortality rate was higher in the elderly (7.2%) than in younger patients (3.0%) (p = 0.02), but the hospital mortality rate was not significantly different in the elderly (18.0%) and younger age groups (14.4%) (p = 0.27). The long-term survival after curative resection in elderly patients was worse than younger patients (p = 0.01). However, when deaths from unrelated medical conditions were excluded from analysis, survival was similar between the two age groups (p = 0.23). A comparison of data for the periods 1982 to 1989 and 1990 to 1996 revealed that the resection rate had increased from 44% to 54% in the elderly, with significantly fewer postoperative complications and lower 30-day and hospital mortality rates. Long-term survival has also improved, although this has not reached a statistically significant level.

CONCLUSIONS

With current surgical management, esophagectomy for carcinoma of the esophagus can be carried out with acceptable risk in the elderly, but intensive perioperative support is required. The improved results of esophagectomy in the elderly in recent years are attributed to increased experience and better perioperative management. Long-term survival was similar to that of younger patients, excluding deaths caused by unrelated medical conditions.

Future directions in esophageal cancer

The incidence of esophageal cancer in the United States has been increasing in recent years. Since multimodality therapy for esophageal cancer has produced discouraging results, recent approaches have focused on molecular biological techniques, positron emission tomography, and minimally invasive surgery to improve pretreatment staging which will facilitate a more accurate assessment of new treatment. This article summarizes the results of studies investigating these approaches and outlines the strategy currently used at the University of Pittsburgh Medical Center.

A prospective randomized comparison of transhiatal and transthoracic resection for lower-third esophageal carcinoma

BACKGROUND

The question whether transhiatal (TH) or transthoracic (TT) resection is most suited for the extirpation of an esophageal cancer remains unresolved. The present study compared the two approaches in a prospective randomized manner.

PATIENTS AND METHODS

Thirty-nine patients with carcinoma of the lower third of the esophagus who were clinically fit for either TH or TT resection were prospectively randomized to TH (20 patients) and TT (19 patients) resection. Patients of the two groups were comparable in age, sex, preoperative tumor staging, and pulmonary and cardiac risks for surgery.

RESULTS

There was no significant difference in the amount of blood loss between the two groups although intraoperative hypotension (systolic <80 mm Hg) occurred more frequently in the TH group (P <0.001). The mean operating time for the TH and TT groups were 174 minutes and 210 minutes, respectively (P <0.001). There was no difference in postoperative ventilatory requirements, cardiopulmonary complication rates, and, mean hospital stay between the two groups. There was no 30-day mortality in either group but there were 3 hospital deaths in the TH group from bronchopneumonia (2 patients) and disseminated malignancy (1 patient). The median survival rates were 16 and 13.5 months, respectively, for the TH and TT groups (P = NS).

CONCLUSIONS

Although there was no demonstrable statistical difference in results between TH and TT approaches, the TT approach is preferred as it allowed for a more controlled operation.

Thoracoscopic esophagectomy for esophageal cancer

BACKGROUND

Minimal access surgery is an alternative to open surgery in esophageal surgery. Its role in cancer resection is controversial.

METHODS

Thoracoscopic esophageal resection was attempted in 22 patients who had increased operative risk. Postoperative outcomes of these patients were compared with the outcomes of 63 patients who underwent open thoracotomy resection during the same period.

RESULTS

Thoracoscopy was completed in 18 patients. Conversion to thoracotomy was necessary because of locally advanced tumor in three patients, and a bypass procedure was performed in another patient because of poor ventilation during thoracoscopy and the finding of metastatic disease. The median thoracoscopy time was 110 minutes (range, 55 to 165 minutes). The total operating times were 240 minutes (range, 165 to 360 minutes) and 250 minutes (range, 190 to 420 minutes) for thoracoscopy and thoracotomy, respectively, p = 0.5. Blood loss was significantly less than that of open resection; medians were 450 ml (range, 200 to 800 ml) and 700 ml (range, 300 to 2500 ml) for thoracoscopy and thoracotomy, respectively, p < 0.01. The median number of lymph nodes removed at thoracoscopy was 7 (range, 2 to 13) compared with 13 (range, 5 to 34) in the thoracotomy group. Bronchopneumonia affected 17% of both groups of patients. Only one patient who was converted to open thoracotomy died. Port site recurrence developed in one patient. Overall survival rates were not significantly different.

CONCLUSIONS

Thoracoscopic esophageal resection was a feasible option. Clear advantages over open thoracotomy were not demonstrated, although patients who were selected for thoracoscopy had worse performance status. This technique deserves further investigation in dedicated centers.

One-stage thoracoscopic oesophagectomy: ligature intrathoracic stapled anastomosis

Thoracoscopic oesophagectomy is usually performed in stages and intrathoracic oesophagogastric anastomosis often requires mini-thoracotomy or extension of the thoracoscopic incisions. This paper describes a new technique whereby such an operation could be completed in one stage and the need to extend the thoracoscopic incisions is obviated.

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.

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.