Dominique Gossot

Thoracoscopic Sympathectomy for Upper Limb Hyperhidrosis: Looking for the Right Operation

BACKGROUNDnThoracoscopic sympathectomy is the most effective treatment for upper limb hyperhidrosis. However, this is offset by the occurrence of a high rate of side effects, such as embarrassing compensatory sweating. Anticipating that a technique that respects the sympathetic chain and divides only the rami communicantes may lead to fewer side effects, we assessed the technique described by R. Wittmoser, comparing it with conventional thoracoscopic sympathecomy.nnnMETHODSnA total of 240 thoracoscopic sympathectomies were performed in 124 patients suffering from upper limb hyperhidrosis. Fifty-four patients underwent a conventional sympathectomy (group TS), 62 underwent division of the rami communicantes with respect to the main trunk (group SS), and 8 underwent both procedures (group TS/SS) because of accidental division of the chain during dissection. The mean follow-up is 8 months.nnnRESULTSnNo recurrence was observed in group TS whereas six (5%) occurred in group SS (p < 0.05). The global rate of compensatory sweating was about the same in both groups: 72.2% in group TS and 70.9% in group SS. However, the rate of embarrassing or disabling compensatory sweating was significantly higher in group TS (50%) than in group SS (21%) (p < 0.001).nnnCONCLUSIONSnAlthough selective division of the rami communicantes results in a significant decrease in the rate of disturbing side effects, it also leads to recurrences that are usually not observed at that level in patients treated with the conventional technique. Therefore other means of achieving the ideal operation should be explored, that is, a technique associated with a high success rate but a minimal number of side effects.

Thoracoscopic esophagectomy: Technique and initial results

To reduce the high morbidity rate associated with esophageal surgery, we have developed a technique of thoracoscopic esophagectomy. A feasibility study was first carried out in an animal model and a specific instrument was developed for this purpose. Esophagectomy using a right thoracoscopic approach was attempted in 15 patients, 13 males and 2 females whose average age was 48 years. Indications consisted of squamous cell carcinoma in 10 patients, adenocarcinoma in 1, and caustic stenosis in 4. We used a technique that consisted of double-lumen tracheal intubation and the creation of five ports. The whole esophagus was mobilized thoracoscopically and the esophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through, and the anastomosis was made in the neck. There were three failures: in 1 patient there was a large tumor, making the exposure unsafe, and, in 2 patients, incomplete lung collapse made exposure of the posterior mediastinum difficult. These 3 cases were converted into a thoracotomy. The thoracoscopic dissection was successful in the remaining 12 patients. The average time of the thoracoscopic stage was 125 minutes. The postoperative course was uneventful in 10 patients. Two patients had a left atelectasis. Although our series is limited, these initial results indicate that thoracoscopic esophagectomy is feasible. However, further evaluation of the technique is needed to assess its benefit in terms of respiratory morbidity.

Clinical statement on the role of the surgeon and surgical issues relating to computed tomography screening programs for lung cancer

Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy (GR); Division of Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota (MSA); Division of Thoracic Surgery, New York Presbyterian–Weill Cornell Medical Center, New York, New York (NKA); Division of Thoracic Surgery, National Cancer Institute, Tokyo, Japan (HA); General Thoracic Surgery, Penrose Cardiothoracic Surgery, Colorado Springs, Colorado (MGB); Department of Thoracic Surgery, Yale University, New Haven, Connecticut (FCD); Arkansas Department of Health, Little Rock, Arkansas (CMD); Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France (DG); Division of Thoracic Surgery, Foothills Medical Center, University of Calgary, Calgary, Canada (SCG); Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (MTJ); Division of Cardiothoracic Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado (JDM); Sentara Thoracic Surgery Center, Mid-Atlantic Cardiothoracic Surgeons, Ltd, Norfolk, Virginia (JRN); Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Antwerp, Belgium (PEVS); Division of Thoracic Surgery, University of Toronto, Toronto, Canada (TKW); and Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, Washington (DEW)

Minimal Access Esophagectomy: Where Are We Up To?

Endoscopic techniques for esophagectomy are disparate. The aim of this article is to describe the main surgical endoscopic techniques applied to esophagectomy and to report their results. In most published series, the benefit in terms of postoperative morbidity cannot be demonstrated. This reflects the fact that postoperative morbidity after esophagectomy is related not only with the type of surgical approach but also with other factors related to the patients status. Finally, the lack of long-term follow-up in most series does not permit to draw conclusion about the relevance of endoscopic esophagectomy. Contrary to other advanced surgical endoscopic procedures, endoscopic esophagectomy has not yet been convincing. Copyright

Visceral lesions occurring during follow-up of melanoma patients: a true place for other diagnosis than melanoma metastasis

Backgroundu2002 Diagnosis of melanoma metastasis is often based on a combination of clinical and radiological examinations in patients with a past history of melanoma. Chemotherapeutic treatment is often proposed without histological proof of the metastatic status.

Thoracoscopic management of pulmonary nodules

SummaryMore and more pulmonary nodules are currently approached via thoracoscopy. We have evaluated the results and the morbidity of a consecutive series of 120 patients operated on by a single surgeon. Patients and methods. One hundred and twenty-two nodules have been resected in 120 patients. The average size of these nodules was 16 mm (3–30 mm). A pre-operative localization technique was used in 61 patients (50%). The procedures were as follows: biopsy (6 cases), wedge-resection (110 cases). A video-assisted lobectomy was performed in 26 cases. Results. The mortality rate was 0.8% (one case of ARDS in the post-operative course of a video-assisted lobectomy). Intra-operative morbidity rate was 1.6% (2 cases of haemorrhage requiring a thoracotomy) and the postoperative morbidity rate was 5%. Six procedures were converted to thoracotomy (5%). The nodules were localized in all cases but 2 (1.6%). The mean post-operative stay was 4.6 days in the whole series and 3.2 days in the series of patients with a sim...