Hani Shennib

Resection of pulmonary nodules using video-assisted thoracic surgery

BACKGROUNDnThe aim of this study was to assess the experience with video-assisted thoracic surgery for the resection of pulmonary nodules.nnnMETHODSnThis voluntary registry (20 centers) included 388 patients with either benign (n = 171) or malignant (n = 217) pulmonary nodules. Pulmonary nodules were located using computed tomography scan-guided injection of methylene blue (59 patients) and hook wire technique (17 patients).nnnRESULTSnVideo-assisted thoracic surgery was converted into thoracotomy in 67 patients (17%) because of technical-emergency in 4, inability to complete resection in 33, and the need to perform lobectomy for cancer through thoracotomy in 30. In other patients, video-assisted thoracic surgery allowed wedge resection in 300 cases and lobectomy in 21 cases. No intraoperative and two postoperative deaths (0.56%) occurred. The complication rate was 8% (n = 31). Mean durations of chest tube placement and hospital stay were 3.3 days (range, 1 to 20 days) and 6 days (range, 1 to 25 days), respectively. Video-assisted thoracic surgery was judged by the surgeon to be a diagnostic procedure 226 times (58%) and a therapeutic procedure 162 times (42%).nnnCONCLUSIONnVideo-assisted thoracic surgery appears to be safe and remains mainly a diagnostic procedure for malignant tumors.

Video-Assisted Thoracic Surgery: Has Technology Found its Place?

BACKGROUNDnSince the introduction of minimally invasive surgical techniques in thoracic surgery in 1990, video-assisted thoracic surgery (VATS) has become the approach for many thoracic operations. The role of VATS has slowly evolved but has not been clearly defined. To better understand the role of VATS, we undertook a survey of practicing thoracic surgeons.nnnMETHODSnA questionnaire was sent to members of the General Thoracic Surgery Club asking the role of VATS in their practice and their opinions regarding appropriate applications, advantages, and limitations of the approach.nnnRESULTSnTwo hundred of the 229 members (87.3%) responded to the questionnaire. In this largely academic (66.3%) group of thoracic surgeons, 72% of whom had more than 10 years experience in general thoracic surgery, VATS was the preferred approach (> 50% response) for the management of pleural disease, lung biopsy, recurrent pneumothorax, and sympathectomy. A majority of respondents thought that VATS was an acceptable approach for the diagnosis of the indeterminate pulmonary nodule and of anterior and posterior mediastinal masses, and for the management of early empyema, clotted hemothoraces, secondary pneumothorax, limited lung cancer treatment, and benign esophageal disease. Video-assisted thoracic surgery was thought to be unacceptable or investigational by a majority for thymectomy, lobectomy, and lung volume reduction operations. Video-assisted thoracic surgery still represents only a small portion of the thoracic procedures performed, but there is a gradual increase in its rate of use, although 38.1% expressed concern regarding overuse. The main limitation was thought to be in the management of oncologic disease.nnnCONCLUSIONSnIt appears that VATS is a valuable addition to the practice of thoracic surgery, but significant limitations exist. Although there appear to be many specific indications defined, there is still a significant evolutionary component.

Surgical revascularization in patients with poor left ventricular function: on- or off-pump?

BACKGROUNDnPatients with left ventricular dysfunction and low ejection fraction (EF) are at high-risk of complication and mortality after coronary artery bypass grafting (CABG). The potential success of off-pump CABG in this high-risk population has yet to be determined. The purpose of this study is to compare the outcome of off-pump coronary artery bypass (OPCAB) and conventional coronary artery bypass (CCAB) in patients with poor left ventricular function, all from a single institution.nnnMETHODSnData on patient demographics, preoperative risk factors, operative and postoperative outcomes were collected retrospectively on all patients having undergone isolated CABG between January 1, 1998, and October 31, 2001.nnnRESULTSnA total of 77 patients (31 OPCAB/46 CCAB) were identified as having an ejection fraction (EF) of < or = 0.35. Of these, 52 had EF < or = 0.30 (21 OPCAB/31 CCAB) and 31 patients had EF < or = 0.25 (10 OPCAB/21 CCAB). Operative mortality was 3.2% after the OPCAB procedure versus 10.9% for the CCAB (p = 0.39). Use of intraaortic balloon pump (6.5%) was rarely required. The OPCAB procedure resulted in significantly less requirement for blood transfusions (p < 0.05), fewer distal anastomoses per patient (p < 0.01), and a higher incidence of atrial fibrillation (p < 0.05) compared with CCAB.nnnCONCLUSIONSnPatients with poor left ventricular function may undergo surgical revascularization using off-pump technique with relatively good results and low mortality levels. The lower number of grafts performed on the off-pump procedure did not seem to affect clinical outcomes.

Double-lung transplantation for cystic fibrosis

One hundred twenty cystic fibrosis patients were accepted for transplantation. Twenty-five patients underwent double-lung transplantation. Twenty-five patients died awaiting transplantation (20.6%). There were 13 female and 12 male patients. Their mean age was 28 years (range, 7 to 34 years), and mean percentage ideal body weight was 76% (range, 58.5% to 91.9%). Most patients were hypoxic and hypercarbic. Two patients underwent tracheal anastomosis, 15 had en bloc bronchial anastomoses, and 8 had sequential single-lung transplants. Operative mortality was 16%; all deaths were related to bleeding from extensive adhesions. Actuarial survival at 1 year was 64%. Rejection and infection were frequent during the first month and decreased thereafter. Airway complications occurred in 5 patients but were amenable to laser therapy and stenting. We conclude that double-lung transplantation is an acceptable modality for the treatment of cystic fibrosis patients with end-stage lung disease. It may be a better alternative to heart-lung transplantation considering the paucity of thoracic organ donors.

Effect of cardiopulmonary bypass on circulating lymphocyte function

Extracorporeal cardiopulmonary bypass (CPB) has been associated with a wide variety of immunological derangements, including a transient postoperative impairment of lymphocyte function. We examined changes in phenotypic and nonspecific cytotoxicity of peripheral blood mononuclear cells after extracorporeal CPB. The peripheral blood samples obtained from 10 patients were subjected to natural killer and cytotoxic T lymphocyte activity assay before and at intervals after CPB. Phenotypic analysis of peripheral blood lymphocytes was performed in 5 patients before and immediately after CPB. We observed a significant increase in peripheral blood CD8+ cells (cytotoxic/suppressor T lymphocytes) (16.1% +/- 2.5% versus 22.5% +/- 2.1%; p less than .005) and a decrease in CD4+ cells (helper/inducer T lymphocytes) (46.1% +/- 3.5% versus 36.1% +/- 3.5%; p less than 0.02) immediately after extracorporeal circulation. The CD8/CD4 ratio in peripheral blood was significantly increased immediately after bypass (0.53 versus 0.80; p less than 0.001). No significant changes in percentages of other leukocyte subsets in peripheral blood were noted. The activity of cytotoxic T lymphocytes and natural killer cells in peripheral blood was impaired on postoperative days 1 and 3 but was restored to preoperative values by removal of mononuclear phagocytes from these cells. The decrease in natural killer cell and cytotoxic T lymphocyte activity in peripheral blood may signify a temporary impairment of the effector arm of the cell-mediated immunity in the post-operative period. The observed changes in peripheral blood phenotype and function may be involved in early organ injury and infectious complications after CPB.

Intraoperative localization techniques for pulmonary nodules

Video-assisted thoracoscopic resection has emerged as a safe procedure for diagnosis and treatment of peripheral pulmonary nodules. Its role alone or with adjuvant radiotherapy in the management of high-risk patients with T1 peripheral lung cancer is currently under evaluation. Most often, inspection of the lung with imaging will reveal surface changes indicative of tumor location (erythema, puckering, scarring), and gentle instrumental probing will allow both visual and tactile discrimination of normal and tumor boundaries. With experience, most lesions can be identified this way. However, when experience is limited, in particular circumstances where lesions are very small, located posteromedially or basomedially, or when there is underlying lung disease (eg, lung fibrosis, radiation changes, adhesions), intraoperative identification of peripheral nodules can be difficult. Computed tomography of the chest helps in planning the operative procedure, the position of the patient, and the ideal ports. Methylene blue injection and insertion of a guidewire into the lung nodule facilitates its identification intraoperatively. We found ultrasound probes to be helpful in defining the tumors margins and its relation to bronchovascular structures, and thus in planning the strategy of resection whether by stapling devices, cautery, or laser dissection.

Bronchoalveolar lavage in lung transplantation

One of the dilemmas in the management of lung allotransplant recipients is our inability to precisely determine the cause of graft dysfunction. Differentiating between lung allograft infection, rejection, atelectasis, or ischemic injury remains a difficult task. Tests directed at identifying systemic abnormalities such as peripheral blood analysis so far have been nonspecific and unlikely to accurately and promptly represent changes occurring within the lungs. Transbronchial biopsy and bronchoalveolar lavage have emerged as two methods with the most potential for aiding in the establishment of diagnosis. This review attempts to provide the readers with a current knowledge of the cellular events in lung allograft and the status of bronchoalveolar lavage in experimental and clinical lung transplantation.

Evolving strategies in minimally invasive coronary artery surgery

It is estimated that approximately 25% of cardiac surgery will be performed through minimal access by the year 2000. While original efforts focused on performing minimally invasive cardiac surgery totally thoracoscopic, and with cardiopulmonary bypass, more recent realistic approaches rely on small targeted incisions and video assisted techniques on the beating heart. Current instrumentations which provide segmental stabilization of the heart eliminate the need for cardioplegic arrest and cardiopulmonary bypass. While early results are encouraging, intermediate and long term clinical outcome and graft patency remain to be determined.

Sublobar resection for lung cancer.

The role of limited lung resection segmentectomy and wedge resection in the treatment of lung cancer has been reviewed. Survival for patients with stage I lung cancer and lesions less than 2 cm is comparable to that of major resections such as lobectomy. The theoretical advantage of limited resection is the simplicity of the procedure and the potential for performing it through lesser invasive techniques. The major drawback at this time which should render it a compromise rather than a choice operation is the increased risk of locoregional recurrence. Until properly conducted clinical trials validate its efficacy in peripheral T1 lung cancer with or without adjuvent therapy, sublobar resection should be limited to patients that are at poor risk of tolerating major lung resection. Sublobar resections however may also play a useful role in treatment of metachronous or synchronous lung cancer.

Application of the lectin-dependent cell-mediated cytotoxicity assay to bronchoalveolar lavage fluid and venous blood samples collected from canine lung allografts.

One of the major obstacles in postoperative management of lung transplant recipients is differentiating between rejection and infection episodes. In addition, there are no reliable methods routinely to monitor lung allografts to ascertain that they are well tolerated by the host. Conventional noninvasive methods such as chest roentgenographs, radio nuclide perfusion scans, and pulmonary function tests used in conjunction with clinical assessment have been shown to be nonspecific (1,2). Other invasive methods used to facilitate the differentiation of rejection from infection are transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL)(3-6) The technique of BAL offers a unique opportunity for the safe and repetitive harvesting of large quantities of graft infiltrating immunocompetent cells from the transplanted lung. The supernatant fluid collected may also contain microorganisms, soluble cytokines, and other mediators that may reflect the changes occurring in the allograft due to infection or rejection.