Robert J. Caccavale

ONE HUNDRED CONSECUTIVE PATIENTS UNDERGOING VIDEO-ASSISTED THORACIC OPERATIONS

Video-assisted thoracic surgery is a new modality that allows visualization of and access to the intrathoracic organs without making a thoracotomy incision. One hundred consecutive patients underwent 113 thoracic procedures using this technique. Eight wedge resections for metastatic lesions, 6 pericardial windows, 1 bronchogenic cystectomy, 4 explorations of the aortopulmonary window, 1 decortication, 5 pleural scleroses, 8 bullous ablations, 25 lung biopsies, 19 wedge resections for carcinoma, 9 explorations of the thorax, 3 lobectomies, 1 esophageal cystectomy, 14 wedge resections for benign lesions, 4 pleurectomies, 1 excision of a neurogenic tumor, 3 mediastinal explorations, and 1 imaged axillary dissection were performed. There was no mortality. Ten patients had complications from which they recovered completely. Patients undergoing video-assisted thoracic operations seem to have reduced postoperative pain, shorter hospitalization, and quicker recovery times. Currently, this new modality appears to have beneficial value for patients; however, only further experience will determine its true merits.

Imaged thoracoscopic surgery: A new thoracic technique for resection of mediastinal cysts

Previously, intrathoracic organs have been approached by either thoracotomy or thoracoscopy. A technique, imaged thoracoscopic surgery, using video optics and projection of images on a screen provides another option for the thoracic surgeon. Two patients with mediastinal cysts, one bronchogenic and one esophageal, underwent surgical removal using imaged thoracoscopic surgery. Postoperative pain was markedly reduced, hospitalization shortened, and recovery accelerated. Numerous complex surgical procedures can be performed using imaged thoracoscopic surgery.

Video-Assisted Thoracic Surgical Non-Rib Spreading Simultaneously Stapled Lobectomy (VATS(n)SSL)

Two hundred consecutive patients underwent a video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy (VATS(n)SSL). Ninety-three were males and 107 were females, ranging in age from 20 to 92 years. Lesions consisted of 171 primary lung carcinomas, 7 metastatic tumors, and 22 benign lesions. Resections included 47 right upper lobe, 18 right middle lobe, 46 right lower lobe, 52 left upper lobe, 26 left lower lobe and 11 bilobectomies, ie, 9 right upper and middle lobes and 2 right middle and lower lobes. Operating time averaged 79.5 minutes, and no patient received a transfusion. Tumors ranged from 1 cm to 9 cm, bronchial stumps were 4 to 5 mm, and length of hospitalization averaged 3.07 days. Complications were minimal, and there was no surgical mortality. No patient developed a bronchopleural fistula or neoplastic port implant. Twenty-four patients have died of metastases. At a median follow-up of 34 months for all stages of carcinoma, there is an overall survival rate of 86%. Survival rate is 92% for stage I. VATS(n)SSL is a new technique for lobectomy that has proven to be beneficial for patients needing resection.

VATS-Argon Beam Coagulator treatment of diffuse end-stage bilateral bullous disease of the lung

Diffuse bullous disease of the lungs remains an unrelentless, debilitating, terminal disease. Intensive medical therapy can give transient relief of symptoms. Thoracotomy and resection has not always been successful and can be associated with an increased mortality and morbidity. Eight patients with end-stage bullous disease, unresponsive to medical therapy and not considered to be candidates for a thoracotomy, underwent unilateral video-assisted thoracic surgical ablation of bullae using the Argon Beam Coagulator. Six men and 2 women ranging in age from 28 to 71 years reported a decrease in dyspnea. Three patients restudied had an increase in forced expiratory volume in 1 second of 34%. Postoperatively, 7 patients had an air leak, pneumonia developed in 2 patients, and 3 patients had massive subcutaneous emphysema after parietal pleurectomy. Hospitalization averaged 13.6 days. All patients made a complete recovery, and each was subjectively improved. Steroid use decreased, oxygen requirements decreased, dyspneic episodes decreased, infections decreased, and endurance increased. In 3 patients with a limited follow-up evaluated postoperatively, video-assisted thoracic surgery and the Argon Beam Coagulator seemed to be beneficial for treating advanced, generalized bullous disease.

One hundred video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading

BACKGROUND This study was performed to evaluate and determine the validity and benefits of video-assisted thoracic surgical simultaneously stapled pulmonary lobectomy without rib spreading. METHODS Between September 1992 and August 1995, 100 consecutive video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading were performed. RESULTS Forty-five male and 55 female patients had 24 right upper, 8 right middle, 29 right lower, 24 left upper, 15 left lower lobectomies for 66 adenocarcinomas, 20 squamous cell carcinomas, 4 large cell carcinomas, 8 benign lesions, and 2 metastatic lesions. Seventy-six patients had negative nodes. Nine patients had positive nodes. Every bronchoscopy was visually and cytologically negative. Forty-nine cervical mediastinoscopies were negative. Operating time for the series averaged 90.3 minutes. Hospitalization averaged 3.5 days for the entire group, but was 2.6 days for the last 20 patients. Lesions ranged from 1.5 to 8 cm, averaging 3.4 cm. There was no surgical mortality, no hemorrhage, no transfusion, and no urgent conversion to an open procedure. No bronchial fistula, vascular fistula, or bronchovascular fistula has occurred. Complications included 6 air leaks, 2 cerebrovascular accidents, 1 infected chest tube site, 2 cases of pneumonitis, and 1 subcutaneous emphysema. CONCLUSIONS Video-assisted thoracic surgical simultaneously stapled lobectomy without rib spreading is a safe operation that can be combined with lymph node sampling. At this early stage, therapeutic outcomes (survival) for resected neoplasms appear similar to results obtained from traditional open techniques.

Reinnervation of the Paralyzed Diaphragm: Application of Nerve Surgery Techniques Following Unilateral Phrenic Nerve Injury

BACKGROUND Unilateral phrenic nerve injury often results in symptomatic hemidiaphragm paralysis, and currently few treatment options exist. Reported etiologies include cardiac surgery, neck surgery, chiropractic manipulation, and interscalene nerve blocks. Although diaphragmatic plication has been an option for treatment, the ideal treatment would be restoration of function to the paralyzed hemidiaphragm. The application of peripheral nerve surgery techniques for phrenic nerve injuries has not been adequately evaluated. METHODS Twelve patients presenting with long-term, symptomatic, unilateral phrenic nerve injuries following surgery, chiropractic manipulation, trauma, or anesthetic blocks underwent a comprehensive evaluation, including radiographic and electrophysiologic assessments. Surgical treatment was offered following a minimum of 6 months of conservative management. Operative planning was based on preoperative and intraoperative testing using one or more established nerve reconstruction techniques (neurolysis, interpositional grafting, or neurotization). RESULTS Measures of postoperative improvement included pulmonary function testing, fluoroscopic sniff testing, and a standardized quality-of-life survey, from which it was determined that eight of nine patients who could be completely evaluated experienced improvements in diaphragmatic function. CONCLUSIONS Based on the favorable results in this small series, we suggest expanding nerve reconstruction techniques to phrenic nerve injury treatment and propose an algorithm for treatment of unilateral phrenic nerve injury that may expand the current limitations in therapy.

Video-assisted thoracic surgery resection of chest wall en bloc for lung carcinoma

A video-assisted thoracic surgery approach to en bloc resection of lung cancer invading the chest wall is described. Using a minimally invasive surgical approach combined with neoadjuvant external beam radiotherapy, complete resection of an upper lobe carcinoma invading two rib segments was performed in a manner that permitted complete resection with curative intent and allowed for rapid recovery.