Yaron Shargall

Thoracoscopic sympathetic clipping for hyperhidrosis: Long-term results and reversibility

OBJECTIVE The study objectives were to assess 1) postoperative satisfaction and the occurrence of compensatory sweating after endoscopic thoracic sympathetic clipping in a consecutive series of patients and 2) the reversibility of adverse effects by removing the surgical clips. METHODS Between June 1998 and March 2006, 727 patients undergoing bilateral endoscopic thoracic sympathetic clipping for hyperhidrosis or facial blushing were prospectively followed for postoperative satisfaction and subjective compensatory sweating. The effect of removing the surgical clips was assessed in 34 patients who underwent a subsequent reversal procedure after endoscopic thoracic sympathetic clipping. Satisfaction and compensatory sweating were assessed using a visual analogue scale ranging from 0 to 10, with 10 indicating the highest degree. RESULTS Follow-up was complete in 666 patients (92%). The median age was 26.9 years, and 383 (53%) were men. The level of sympathetic clipping was T2 in 399 patients (55%), T2+3 in 55 patients (8%), and T3+4 in 273 patients (38%). Median follow-up was 10.4 months (range 0-83 months). Excellent satisfaction (8-10 on visual analogue scale) was seen at last follow-up in 288 (74%) of the T2 group, 33 (62%) of the T2+3 group, and 184 (85%) of the T3+4 group. Postoperative satisfaction was significantly higher in the T3+4 group when compared with the T2 or T2+3 groups (P < .01). Severe compensatory sweating (8-10 on the visual analogue scale) was reported in 42 (13%) of the T2 group, 11 (28%) of the T2+3 group, and 17 (8%) of the T3+4 group. Postoperative compensatory sweating was significantly lower in the T3+4 group when compared with the T2 or T2+3 groups (P < .05). Thirty-four patients have subsequently undergone removal of the surgical clips after endoscopic thoracic sympathetic clipping. Follow-up was complete in 31 patients. The reasons for removal included severe compensatory sweating in 32 patients, anhydrosis of the upper limb in 4 patients, lack of improvement or recurrence of hyperhidrosis in 5 patients, and other adverse symptoms in 5 patients. The reversal procedure was done after a median time of 11.0 months (range 1-57 months) after endoscopic thoracic sympathetic clipping. The initial level of clipping was T2 in 21 patients, T2+3 in 7 patients, and T3+4 in 6 patients. There was a trend toward fewer subsequent reversal procedures in the T3+4 group when compared with the T2 or T2+3 groups (P = .06). Fifteen patients (48%) reported a substantial decrease in their compensatory sweating (5-10 on the visual analogue scale) after reversal. Thirteen patients (42%) reported that their initial hyperhidrosis or facial blushing has remained well controlled (8-10 on the visual analogue scale) after reversal. There was no significant relationship between the original level of clipping and the interval between endoscopic thoracic sympathetic clipping and the subsequent reversal and reversibility of symptoms. CONCLUSION When compared with endoscopic thoracic sympathetic clipping at the T2 or T2+3 levels, endoscopic thoracic sympathetic clipping at the T3+4 level was associated with a higher satisfaction rate, a lower rate of severe compensatory sweating, and a trend toward fewer subsequent reversal procedures. Subjective reversibility of adverse effects after endoscopic thoracic sympathetic clipping was seen in approximately half of the patients who underwent endoscopic removal of surgical clips. Although yet to be supported by electrophysiologic studies, reversal of sympathetic clipping seems to provide acceptable results and should be considered in selected patients.

Role of Lung Transplantation in the Treatment of Bronchogenic Carcinomas for Patients With End-Stage Pulmonary Disease

PURPOSE To determine the role of lung transplantation in the treatment of patients presenting with bronchogenic carcinoma and end-stage lung disease. METHODS An international survey was conducted to determine the outcome of patients with bronchogenic carcinoma in the explanted lung at the time of transplantation. A group of 69 patients was collected from 33 centers. RESULTS Twenty-six patients underwent 29 lung transplantations for advanced multifocal bronchioloalveolar carcinoma (BAC) as the primary indication for transplantation, and 13 developed a recurrence, with an overall 5-year actuarial survival of 39%. Incidental bronchogenic carcinomas classified as stage I (n = 22), II (n = 12), and III (n = 2), or as incidental multifocal BAC (n = 7), were found in the explanted lung of the remaining 43 patients. The 5-year actuarial survival was 51% in patients with stage I carcinomas, and was significantly better than for patients with stage II and III carcinomas (survival of 14%) or with incidental multifocal BAC (survival of 23%). Time from transplantation to recurrence and from recurrence to death was significantly longer in patients with multifocal BAC than in patients with other types of bronchogenic carcinoma. In addition, the site of recurrence was limited to the transplanted lung in 88% of the patients with multifocal BAC, whereas it was always widespread in patients with other types of bronchogenic carcinoma. CONCLUSION This study demonstrates that long-term survival can be achieved after lung transplantation in patients with stage I bronchogenic carcinoma or with advanced multifocal BAC.

Thoracoscopic Nuss Procedure for Young Adults With Pectus Excavatum: Excellent Midterm Results and Patient Satisfaction

BACKGROUND Chest wall remodeling by substernal placement of a Nuss bar is the treatment of choice for children with pectus excavatum; however, it has not yet gained widespread acceptance in adults. We demonstrate that thoracoscopic Nuss bar insertion in young adults is safe and leads to excellent results. METHODS Adult patients who underwent thoracoscopic Nuss bar insertion at one institution between 2006 and 2012 were identified. Data on demographics, postoperative outcomes, quality of life, and cosmetic satisfaction was collected. A validated single-step quality of life survey was administered to patients. Students t test and the Wilcoxon rank sum test were used for statistical analysis. RESULTS Seventy-three patients (65 male, 8 female) with a median age of 20 years (range, 16 to 51) were included. The median follow-up was 44.6 months (range, 36.9 to 73.26). Most patients (59 of 73, 81%) had one bar placed. The median length of hospital stay was 5 days (range, 3 to 9) and the median duration of epidural anesthesia was 3 days (range, 0 to 7). There were 4 reoperations (5.5%) in the immediate postoperative period: 2 for bar displacement and 2 for poor cosmesis. All reoperations were performed thoracoscopically. Other postoperative complications included pneumothorax (3 of 73, 4.1%) and ileus (1 of 73, 1.3%). Fifty-one patients participated in a quality-of-life survey (73% response rate). The mean self-esteem score improved from 4.6 of 10 preoperatively to 6.5 of 10 postoperatively (p=0.002). The social impact of the pectus deformity became less significant (mean preoperative score 3.6, mean postoperative score 2.8, p=0.02). The severity of initial postoperative pain was much improved on follow-up. The vast majority of patients (41 of 51, 80%) were satisfied with the cosmetic result, and 96% (49 of 51) would opt to have the surgery again. CONCLUSIONS For young adults who wish to correct their pectus deformity, a thoracoscopic Nuss procedure is safe and results in a high rate of patient satisfaction, significant improvement in self-image, and excellent midterm cosmetic results.

Video-Assisted Mediastinoscopy Compared With Conventional Mediastinoscopy: Are We Doing Better?

BACKGROUND Conventional mediastinoscopy (CM) is recently being replaced by video-assisted mediastinoscopy (VAM), with potentially better yield and better safety profile for VAM. METHODS All 645 mediastinoscopies (505 CM, 140 VAM) performed between May 2004 and May 2008 were reviewed. Numbers of stations biopsied, total number of lymph nodes dissected, pathology results, and complications were recorded. Patients were divided into two groups: staging for lung cancer group (n = 500) and diagnostic group (n = 145). The staging group was further analyzed, using 304 patients who eventually underwent thoracotomy to evaluate accuracy and negative predictive value of mediastinoscopy, comparing between the two methods (233 CM, 71 VAM). RESULTS Average age was 65 years (range, 26 to 91), and 382 were male. There was no mortality. Eight complications (1.2%) occurred, more in the VAM group (3.8%) than in the CM group (0.8%; p = 0.04). The total number of dissected nodes was higher in the VAM group than in the CM group (7.0 +/- 3.2 versus 5.0 +/- 2.8, p < 0.001), and so was the number of stations sampled (3.6 versus 2.6, p < 0.01). Sensitivity was higher for VAM (95% versus 92.2%, p = not significant), and so was the negative predictive value (98.6% versus 95.7%, p = not significant). Most false negative biopsies (8 of 11, 73 %) occurred in station 7. CONCLUSIONS Both methods are safe. More lymph nodes and stations were evaluated by VAM, with trend toward higher negative predictive value. The higher rate of minor complications seen with VAM might be related to a more aggressive and thorough dissection.

Hyperhidrosis: What is it and Why Does it Occur?

Hyperhidrosis is excessive sweating in response to heat or emotional stimuli beyond physiologic need. The ailment is not new and has been described in the literature dating back several centuries. It can be classified as either primary or secondary based on its etiology. Mechanisms that cause excessive sweating can be traced to the sympathetic nervous system, part of the autonomic nervous system. It has been speculated that the primary abnormality is central, and that the hypothalamic sweat center that controls the palms, axillae, and soles is distinct in hyperhidrosis individuals.

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: the Toronto experience.

BACKGROUND Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH). However, this surgery remains performed in few experienced centres only. The goal of the study is to review our overall experience since the implementation of our program in August 2005. METHODS Review all patients referred to our program between August 2005 and July 2011. RESULTS Among 84 consecutive patients referred to our program, 52 patients underwent elective PEA and 6 emergency PEA. After PEA, 74% patients were extubated within 2 days, 71% were discharged from the intensive care unit within 4 days and 64% were discharged from hospital within 15 days. One patient undergoing elective surgery and 2 patients undergoing emergency surgery died within 30 days of surgery for an operative mortality of 1.9% after elective pulmonary endarterectomy and an overall operative mortality of 5.2%, when the 6 emergency operative cases were included. The total pulmonary vascular resistance decreased from 965±445 to 383±162 dynes per second per cm(-5) and was associated with significant improvement in World Health Organization/New York Heart Association (WHO/NYHA) functional class, 6 minutes walk distance, echocardiographic findings, and brain natriuretic peptide level at 6 months after PEA. After a median follow-up of 23 months (1-65 months), 3 patients had to be started on targeted PH therapy for deterioration of their (WHO/NYHA) functional class. CONCLUSIONS Elective PEA can be performed with limited risk, and results in excellent early and long-term outcome. All patients diagnosed with chronic thromboembolic PH should be referred for consideration of PEA in a specialized centre.

Surgical Conditions of the Diaphragm: Anatomy and Physiology

The diaphragm (Greek: dia = in-between, phragma = fence) is a musculoaponeurotic structure that serves as the most important respiratory muscle and the separating structure between the abdominal and thoracic cavities. This article reviews the anatomic components of the diaphragm, its pivotal role in respiration and in the gastroesophageal mechanism, and the surgical implications of the anatomic structuring.

Feasibility of blood conservation strategies in pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

Blood transfusion requirements were reviewed for a consecutive series of 25 patients undergoing elective pulmonary endarterectomy (PEA) between August 2005 and March 2009 in our institution. Patients were divided into two groups based on the implementation of a conservative blood transfusion algorithm that combined antifibrinolytic therapy, intraoperative blood sequestration, blood salvage and lack of correction of coagulation parameters in the absence of ongoing bleeding. Despite similar perioperative coagulation profiles in the two groups, the introduction of a conservative blood transfusion algorithm was associated with a significant increase in the number of patients receiving no homologous blood products. Of 16 patients who underwent surgery after the introduction of the algorithm, nine (56%) required no homologous blood products and five (31%) required one or two units of homologous red blood cells only. The international normalized ratio normalized within six to 12 hours after discontinuation of cardiopulmonary bypass without transfusion of fresh frozen plasma or platelets in 13 of the 16 patients. In conclusion, a conservative blood transfusion strategy allows PEA to be safely performed with no or minimal blood product transfusions in a majority of patients despite deep hypothermic circulatory arrest.

Postdischarge venous thromboembolic complications following pulmonary oncologic resection: An underdetected problem

OBJECTIVES To determine the prevalence of delayed postoperative venous thromboembolism (VTE) in patients undergoing oncologic lung resections, despite adherence to current in-hospital VTE prophylaxis guidelines. METHODS Patients undergoing lung resection for malignancy in 2 tertiary-care centers were recruited between June 2013 and December 2014. All patients received guideline-based VTE prophylaxis until hospital discharge. Patients underwent computed tomography chest angiography with pulmonary embolism (PE) protocol and bilateral lower extremity venous Doppler ultrasonography at 30 ± 5 days after surgery to determine the incidence of postoperative VTE. Univariate analysis was used to compare the VTE and non-VTE groups. RESULTS A total of 157 patients were included, 45.9% were men with a mean age of 66.7 years. VTE prevalence was 12.1% with a total of 19 VTE events, including 14 PEs (8.9%), 3 deep venous thromboses (DVTs) (1.9%), 1 combined PE/DVT, and 1 massive left atrial thrombus originating from the pulmonary vein stump after pulmonary lobectomy. PE events occurred in the operated lung 64% of the time and 4 patients (21.1%) were symptomatic at diagnosis. The 30-day mortality rate of VTE events was 5.2%, with 1 patient who died secondary to massive in situ ipsilateral PE following readmission to the hospital. Univariate analysis did not demonstrate significant differences between the VTE and non-VTE populations with regard to baseline characteristics. CONCLUSIONS Despite adherence to in-hospital standard prophylaxis guidelines, VTE events are frequent, often asymptomatic, and with associated significant morbidity and mortality. More research into the potential role of predischarge screening and extended prophylaxis is warranted.

The Use of Robotic-Assisted Thoracic Surgery for Lung Resection: A Comprehensive Systematic Review

The primary objective of this study is to systematically review all pertinent literature related to robotic-assisted lung resection. Robotic-assisted thoracic surgery (RATS) case series and studies comparing RATS with video-assisted thoracoscopic surgery (VATS) or thoracotomy were included in the search. In accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, 2 independent reviewers performed the search and review of resulting titles and abstracts. Following full-text screening, a total of 20 articles met the inclusion criteria and are presented in the review. Amenable results were pooled and presented as a single outcome, and meta-analyses were performed for outcomes having more than 3 comparative analyses. Data are presented in the following 4 categories: technical outcomes, perioperative outcomes, oncological outcomes, and cost comparison. RATS was associated with longer operative time, but did not result in a greater rate of conversion to thoracotomy than VATS. RATS was superior to thoracotomy and equivalent to VATS for the incidence of prolonged air leak and hospital length-of-stay. Oncological outcomes like nodal upstaging and survival were no different between VATS and RATS. RATS was more costly than VATS, with most of the costs attributed to capital and disposable expenses of the robotic platform. Although limited by a lack of prospective analysis, lung resection via RATS compares favorably with thoracotomy and appears to be no different than VATS. Prospective studies are required to determine if there are outcome differences between RATS and VATS.