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Present clinicopathologic staging of non-small cell lung cancer is limited in its ability to provide more than a general prognostic estimate in patients with lung cancer who have resectable disease. This study was performed to identify whether the ability to adapt tumor tissue from resectable (stage I to IIIa) non-small cell lung cancer was associated with a poorer prognosis and an increased risk for early tumor recurrence. We attempted to culture a tumor specimen obtained from 90 patients with resectable non-small cell lung cancer. We used a culture medium conditioned by exposure to the lung cancer cell line A549-1, a known producer of autocrine lung cancer growth factors, and provided tumor colony scaffolding using a feeder layer of inactivated fibroblasts, and found these measures improved tumor culture yields. Twenty-two cell lines were obtained, a success rate of 24.4%. Tumor recurrences were more common (79%) among the culture-positive patients than among the culture-negative patients (37.5%; p < 0.002). For all patients, survival at 19 months in the culture-positive patients was 50.0%, compared with 83.6% in the culture-negative patients (p < 0.005). The median survival for the culture-positive patients was 15 months, versus 21.7 months for the culture-negative patients (p < 0.004). The establishment of a culture was a predictor of shortened survival for patients with stage I disease. In patients with stage I disease, survival at 19 months was 54.5% for the culture-positive patients, versus 89% for the culture-negative patients (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical courses of two patients with moderate atherosclerotic aneurysmal dilation of the upper abdominal aorta suffering significant thrombo-embolic sequelae following transhiatal esophagectomy are presented. Inadvertent dislodgement of debris from the diseased aorta during the course of the hiatal and intrathoracic "blunt" dissection was felt to be responsible for this uncommon postoperative problem. This potential complication should be kept in mind when operating near the esophageal hiatus during the course of esophagectomy in such vasculopathic patients.

Indeterminate pulmonary nodules (IPN) in transplant patients create a diagnostic and therapeutic challenge. Patients who are transplant candidates or have already undergone organ transplantation require diagnostic clarification of IPN which may represent oncologic and/or infectious disease processes. Between December 1991 and January 1993, we performed 43 needle-localized thoracoscopic resections (NLTR) on 40 patients for IPN considered too small for less invasive diagnostic techniques. Four of these patients were candidates for orthotopic liver transplantation (OLT) and required exclusion of either extrahepatic malignancy or pulmonary infection before proceeding with transplantation. The 5th patient had undergone OLT for an unresectable hepatocellular carcinoma, and NLTR confirmed the presence of pulmonary metastatic disease. Of the 4 OLT candidates, 2 had pathologically confirmed metastases from their primary hepatic malignancy and did not undergo transplantation. The remaining 2 OLT candidates had benign pulmonary processes (hamartoma, hyaline plaque) and underwent successful OLT. In all patients, the IPN was successfully identified with NLTR. There were no complications. NLTR is a reliable and well-tolerated method to diagnose IPN in transplant patients.

Frozen-section (FS) analysis of mediastinal lymph nodes is commonly used in the staging of lung cancer and the evaluation of diagnostic tissue at mediastinoscopy. This approach facilitates definitive surgical intervention in a single operation and reduces costs. However, FS analysis can be labor intensive for the pathology department and time-consuming while the patient is anesthetized. Imprint cytology is more rapid than the FS procedure (average, 2 minutes versus 11 minutes per node) and allows more extensive sampling of the specimen. In this prospective study, we compared the diagnostic accuracy of imprint cytology and permanent sections on 121 mediastinal lymph nodes from 38 patients. There were no false-positive results and one false-negative result, although that patient was correctly classified based on positive cytology from another node. The sensitivity was 96.6%, the specificity was 100%, and the predictive value of a positive result was 100%, as no false-positives results were observed. The predictive value of a negative result was 98.9%, and the overall efficiency was 99.2%. These results compare favorably with those in other studies comparing the diagnostic accuracy of imprint cytology with that of FS analysis and with reported accuracy rates of FS technique. Our findings confirm the usefulness of this technique as an adjunct or substitute for FS analysis in the intraoperative pathologic evaluation of mediastinal lymphadenopathy.

Providing adequate ventilation and unencumbered access for manipulation of the airway or esophagus during rigid endoscopic procedures can be problematic. We describe a method of nasotracheal high-frequency jet ventilation that is ideally suited for many patients requiring rigid upper endoscopy.

The prevalence and severity of chronic pain after video-assisted thoracic surgery for pulmonary resection remains to be defined. Three hundred forty-three of 391 consecutive patients 3 to 31 months after pulmonary resection by lateral thoracotomy (n = 165) or video-assisted thoracic surgery (n = 178) responded to a questionnaire aimed at comparing the relative occurrence of chronic postoperative pain after video-assisted thoracic surgery and lateral thoracotomy approaches for pulmonary resection. Patients less than 1 year after operation (video-assisted thoracic surgery = 142; thoracotomy = 97) and more than 1 year after operation (video-assisted thoracic surgery = 36; thoracotomy = 68) were analyzed as individual cohorts. Chronic pain was assessed by questioning patients about the presence and the intensity of discomfort on the side of the operation (using a visual analog scale) and their need for analgesic medication and the presence of ongoing limitations in shoulder function. Patients who underwent video-assisted thoracic surgery (less than 1 year from operation) had less pain and subjective shoulder dysfunction although their pain medication requirements were similar to those of thoracotomy patients less than 1 year from operation. After 1 year, there was no significant difference in these "pain related" morbidity parameters between the two surgical approach groups (video-assisted thoracic surgery or thoracotomy).

Although airway, arterial, and venous connections required for lung transplantation appear simple, in practice we have encountered morbid early stenosis and obstructions, which are now avoided by technical modifications gradually made since 1985 in 134 cases (60 single lung and 74 double lung). Our initial eight double lung transplant procedures were done with tracheal anastomoses and omental wraps, but ischemic disruption, with a 75% (6 of 8) rate of complications, resulted in the subsequent use of bi-bronchial connections. A total of 192 bronchial anastomoses were reviewed (60 single lung, 66 double lung). Although all anastomoses were constructed between the donor trimmed to one to two rings above the upper lobe origin and the host divided at its emergence from the mediastinum, the suture technique has evolved. Nine (32%) of 28 cases with early bronchial anastomoses with end-to-end suture and intercostal muscle wrap had ischemic or stenotic complications, but the telescoping technique without wrap in 164 bronchial anastomoses reduced the problem to 12% (19 of 164). Twelve anastomoses required temporary intraluminal stenting. Vascular anastomotic obstructions occurred in five arterial (excessive length 2, short allograft artery 1, restrictive suture or clot 2) and two venous (excessive length 1, restrictive suture or clot 1) connections. Suspicion of arterial obstruction was prompted by persisting pulmonary hypertension and reduced flow to the allograft measured by postoperative nuclear scan and hypoxia. Venous obstructions were suggested by persisting radiographic and clinical pulmonary edema. Modifications of earlier techniques have improved our early success in lung transplantation and might be considered by others entering this demanding field.

Transhiatal extension of pancreatic pseudocysts is an infrequent cause of symptomatic mass lesions in the posterior and middle mediastinum. Delayed recognition is common. An alcoholic patient with spontaneous fistulization between a mediastinal pseudocyst and distal esophagus is presented.

One hundred thirty-eight consecutive, nonrandomized patients, with equivalent demographic and preoperative physiologic parameters, underwent either a video-assisted thoracic surgical (VATS) approach (n = 81) or a limited lateral thoracotomy (LLT) approach (n = 57) to accomplish pulmonary resection for peripheral lung lesions (< or = 3 cm in diameter). Wedge resection was done in 74 VATS patients and 19 LLT patients. Seven patients underwent VATS lobectomy and 38 patients had lobectomy performed through an LLT. Pain was quantitated by postoperative narcotic requirements, the need for intercostal/epidural analgesia, and patient perception of pain index scoring. Shoulder and pulmonary function (forced expiratory volume in 1 second) were measured preoperatively, 3 days postoperatively, and at 3 weeks of follow-up. Patients undergoing VATS experienced significantly less postoperative pain. No patients undergoing VATS required intercostal block/epidural analgesia; 31 LLT patients (54%) required this treatment for breakthrough pain (p = 0.001). Narcotic requirements were less (p = 0.05) among VATS patients, which correlated with lower perception of pain index after operation for VATS patients. Shoulder girdle strength was equally impaired at day 3, but function was more improved in VATS patients at 3 weeks (p = 0.01). Patients undergoing wedge resection alone by LLT had greater impairment in early (day 3) pulmonary function (forced expiratory volume in 1 second) (p = 0.002); this difference from VATS was not sustained at 3 weeks. Video-assisted thoracic surgery is associated with reduced pain, shoulder dysfunction, and early pulmonary impairment compared with LLT for select patients requiring pulmonary resection.

In the past 2 years, the development of video-assisted thoracic surgery (VATS) has allowed thoracoscopy to rapidly evolve from a primarily diagnostic tool to a therapeutic tool with potentially useful applications. As with laparoscopy, the initial enthusiasm for VATS must be tempered by the reality of technical inadequacies, complications, and results that have yet to withstand careful scientific scrutiny. The purpose of this study was to determine the technical feasibility of a VATS lobectomy. Forty-four patients with primary bronchogenic carcinoma were evaluated and accepted as potential candidates for VATS lobectomy. After complete preoperative staging, these patients were in clinical stage I. All patients had normal arterial blood gases and adequate pulmonary function (forced expiratory volume in 1 second > 1.5 L) to tolerate a lobectomy. At the time of operation, 3 patients were found to have N2 disease and were excluded from the study. In 35 of the remaining 41 patients, a successful VATS lobectomy was accomplished through two thoracoscopy ports and a non-rib-spreading 6- to 8-cm "access" thoracotomy. There were no major intraoperative complications that necessitated conversion to an open thoracotomy. Mean operative time was 153 +/- 26 minutes. All 35 patients recovered uneventfully with a mean hospital stay of 5.7 +/- 1.6 days. A VATS lobectomy is technically feasible using our approach and is potentially safe. However, major advances in thoracoscopy imaging and instrumentation are necessary before this procedure will have the potential for widespread acceptance. Also, the advantages of VATS lobectomy over accepted surgical techniques will have to be carefully documented in randomized trials.

Introduction of the interleukin-4 (IL-4) gene into cells derived from human tumor tissue provides a means for generating a specific tumor vaccine. Such a vaccine could be produced by either transducing tumor-derived stromal cells with the IL-4 vector and coinjecting tumor cells, or by transducing the tumor cells themselves. We have developed a protocol for culturing cells from non-small cell lung tumors and routinely produce tumor cultures from 25% of tumors, and stromal cultures from > 80% of specimens. Several of these cultures were transduced with the incompetent retroviral vector G1NaSvi4.25, which encodes the human IL-4 cDNA and the G418-resistance gene. Infection of cells by viral titers of 2-5 x 10(4) plaque-forming units/ml, and a multiplicity of infection of 0.1:1 to 1:1 yielded transfer efficiencies of 3.3-32.0 transfectants per 10(4) cells in six of eight attempts. Following selection with the neomycin analog G418, IL-4-producing cells were isolated. IL-4 titers ranged from 142 to 593 U/ml/10(6) in a 24-h collection. Successful transfer of the IL-4 gene was demonstrated by polymerase chain reaction amplification of cDNA derived from reverse-transcribed total RNA, by immunohistochemistry, and by enzyme-linked immunosorbent assay. The IL-4-producing cells were shown to stimulate the proliferation of autologous peripheral blood lymphocytes in one individual by 7.5-fold over control and by 4.1-fold over non-IL-4 producing tumor cells.(ABSTRACT TRUNCATED AT 250 WORDS)

The ND:YAG surgical laser is a safe and effective method for resection of pulmonary nodules using VATS. It may be used as the primary resecting tool or as an adjunct to endoscopic stapling techniques to provide optimal pulmonary tissue preservation, and to avoid injury to the lung from inappropriate stapler applications. Thoracoscopic laser resection is particularly suited for deep lesions and for surface nodules where staplers are inadequate. Laser ablation of bullous disease using thoracoscopy offers a minimally invasive method of treating symptomatic patients with complications from dominant bullae.

The technique of video-assisted thoracic surgery (VATS) offers a new approach for management of effusive diseases of the pericardium. By the thoracoscopic approach, which can be performed through either the right or left chest cavity, an extensive pericardiectomy equivalent to one performed through a thoracotomy can be performed. Patients with benign effusive pericarditis, malignant pericardial effusions with a good prognosis, post-radiation pericarditis, purulent pericarditis, and delayed tamponade after open cardiac procedures can be optimally managed by video-assisted techniques.

Traditional nonoperative diagnostic approaches to the indeterminate solitary pulmonary nodule include bronchoscopy and percutaneous needle biopsy. Although both methods are minimally invasive, the diagnosis of the small, peripheral nodule may remain elusive. Open thoracotomy is often required when these methods fail to obtain a diagnosis. Between January 1991 and June 1992, 242 patients with indeterminate solitary lung nodules underwent thoracoscopic excisional biopsy as the primary diagnostic method. Wedge excisions of the nodules were all performed by thoracoscopic techniques using an endoscopic stapler alone (72%), neodymium:yttrium-aluminum garnet laser (18%), or both (10%). A definite diagnosis was obtained in all patients. Two patients required conversion to thoracotomy to locate the nodule (both malignant). A benign diagnosis was obtained in 127 patients (52%) and a malignant diagnosis in 115 (48%). Of the malignant nodules, 51 (44%) were primary lung cancer and 64 (56%) were metastases. All patients diagnosed with primary lung cancer having adequate pulmonary reserve (n = 29) underwent formal open lung resection during the same procedure. There was no mortality, and significant morbidity was limited to atelectasis in 3 patients (1.2%), pneumonia in 2 patients (0.8%), and prolonged air leak more than 7 days in 4 patients (1.6%). Average hospital stay for patients having thoracoscopy only (n = 213) was 2.4 days (range, 1 to 12 days). Thoracoscopy offers a minimally invasive approach for the diagnosis of the indeterminate solitary nodule. It has advantages over traditional diagnostic methods of being virtually 100% sensitive and 100% specific with no mortality and minimal morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracoscopic instruments of today are rooted in surgical innovations which began over 100 years ago. The advent of modern video-optical equipment and endoscopic techniques has given birth to a wide array of new instruments and surgical uses. This process is still in full swing. An overview of the most important developments is given, and future lines of development are explored.

Objective: This study assessed the reliability and safety of VATR for treatment of peripheral T1 lung cancer in high-risk patients., Summary Background Data: Surgical resection is the best therapy for stage I lung cancer. Patients with poor cardiopulmonary status or those who are elderly (> 75 years of age) are considered to be at high risk from thoracotomy and are frequently referred for radiation therapy or expectant palliative management. Data from previous studies suggest that survival with wedge resection is similar to that with lobectomy. The authors propose VATR, which is minimally invasive, as a therapeutic option in patients considered to be at high risk for resection by thoracotomy., Methods: Between November 1990 and November 1992, more than 400 thoracoscopic lung resections were performed. Thirty patients with poor pulmonary function (forced expiratory volume FEV1] < 1 L or < 35% predicted; arterial oxygen tension [PaO2] < 60 mmHg on room air; diffusion capacity [DCO] < 40%) underwent 31 VATRs (1 patient had a staged procedure for bilateral synchronous lung cancers). All patients had T1 peripheral lesions with no bronchoscopically visible lesions. Computed tomography of the chest revealed no evidence of mediastinal disease in all patients., Results: Patients had a mean FEV1 value of 0.9 L (38% predicted) and a mean age of 71 years. Tumors were located in left upper lobe (LUL) in 13 patients, in right lower lobe (RLL) in 7 patients, in right upper lobe (RUL) in 6 patients, in left lower lobe (LLL) in 4 patients, and in right middle lobe (RML) in 1 patient. Computed tomography-guided wire localization, methylene blue surface injection, and intraoperative ultrasonography were used to assist in defining difficult lesions. All lesions were successfully resected without converting to thoracotomy. One patient died on the 34th postoperative day of myocardial infarction (operative mortality rate of 3%). Five patients had prolonged air leaks (< 5 days), with a median chest tube time of 3 days. Two patients experienced pneumonia., Conclusion: The authors concluded that VATR is a safe and reliable procedure for treatment of peripheral T1 lung cancer in high-risk patients. Long-term follow-up will be required to determine the efficacy of this procedure regarding survival and locoregional recurrence.

Thoracoscopic techniques were used to perform a pericardiectomy in 35 patients with purely effusive pericardial disease after medical management and pericardiocentesis had failed to be effective. There were no intraoperative complications and postoperative complications were few. Two cases of dysrhythmia and 2 cases of pneumonia occurred postoperatively. Malignancy was identified as the cause in 18 patients and there were benign causes in the remaining 17. The hospital stay in the group with benign effusions was 4.6 days. There were no recurrences of pericardial effusions and no constrictive changes developed during a mean follow-up of 9 months. Fourteen (40%) patients had pleural or pulmonary abnormalities that were managed simultaneously thoracoscopically. These abnormalities included 2 pleural masses, 2 pulmonary nodules, and 12 pleural effusions. In 8 instances, the pericardiectomy was performed from the right pleural cavity in order to address the pleural or pulmonary problem. Thoracoscopic pericardial resection has proved safe and effective. It allows a wider pericardial resection than that usually permitted by the subxiphoid route, and should lessen the pain and the number of pulmonary complications, compared with open thoracotomy. An additional advantage is that it allows the visualization and management of simultaneous pleural and pulmonary abnormalities.

Pulmonary lesions in patients with malignancy often require resection to provide prognostic information and to dictate further therapy. Metastasectomy may also favorably influence survival in select patients with favorable tumor histologies. Seventy-two patients with a history of malignancy and new lung lesions identified by high resolution computed tomography underwent thoracoscopic resection. The operative approach was with standard techniques using two or three trocar sites. Preoperative needle localization was used in 13 patients with small lesions that were not immediately subpleural. All target lesions were identified at thoracoscopy. Exploratory thoracoscopy was followed by parenchymal sparing wedge resection with the endoscopic stapler, the neodymium:yttrium-aluminum garnet laser, or both. Histologic analysis revealed metastatic disease in 63 patients and benign disease in 9 patients. The mean diameter of the lesions was 1.6 cm. The mean duration of chest tube drainage and postoperative hospital stay were 2.1 and 4.1 days, respectively. Thoracoscopic resection appears to be a valid approach for diagnostic resection of presumed metastases. The role of thoracoscopy in therapeutic metastasectomy remains to be defined.

Significant advances in surgical equipment, video monitoring, and endoscopic surgical techniques have expanded the role of thoracoscopy to include pulmonary resection. One limitation of the thoracoscopic technique is the loss of manual palpation to identify the nodule that is either too small or too deep beneath the pleural surface. We describe the techniques used in 300 thoracoscopic pulmonary resections that have aided in identification of pulmonary nodules. These techniques include careful preoperative assessment of the computed tomogram, preoperative injection of methylene blue, or a needle localizing system to identify the nodule. Intraoperative techniques include instrument palpation, digital palpation, and intraoperative ultrasonography. It should be possible to identify the majority of pulmonary nodules at the time of thoracoscopy with these localizing techniques. All nodules were successfully identified in our last 200 thoracoscopic resections.

Thoracoscopy would seem to have several potential advantages over open techniques in terms of the attendant postoperative pain and pulmonary complications. Although many questions exist pertaining to the use of thoracoscopy in the therapeutic management of malignancies of the mediastinum, its use for benign disorders appears desirable. Since December 1990, we have removed 9 mediastinal cysts using a thoracoscopic procedure. These included 7 bronchogenic or enteric cysts, 1 pericardial cyst, and 1 thymic cyst. The average cyst size was 4.2 cm, with 11 cm the largest diameter. Complete removal of the cysts was possible in all but 1 case, in which the cyst adhered to vital structures. A portion of the cyst wall was therefore left intact and the mucosa cauterized. The average hospital stay in these patients was 2.1 days, and there were no intraoperative or postoperative complications. All cysts were benign. The resection of mediastinal cyst using thoracoscopic procedures and based on standard surgical indications would seem to be appropriate. Thoracoscopic removal should be considered as an alternative method to resection of mediastinal cysts.

As with any operative procedure, careful preoperative and intraoperative planning are vital to achieving a safe and effective video-assisted thoracic surgical intervention. We outline some of our basic strategies for enhancing the success of this approach in the management of thoracic surgical problems.

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical mediastinoscopy is useful for the diagnosis of paratracheal lymph node metastasis from bronchogenic carcinoma. Access to adenopathy in the aorticopulmonary window, anterior mediastinal, periazygos, and subcarinal lymph nodes is difficult with this technique. Operative visibility in these locations through anterior mediastinotomy, the Chamberlain procedure, is limited. We have used thoracoscopic mediastinal exploration in 40 patients with computed tomographic scan evidence of enlarged aorticopulmonary window (n = 30) or enlarged right periazygos or subcarinal lymph nodes (n = 10). This procedure was used primarily as an adjunct to cervical mediastinoscopy in the staging of bronchogenic carcinoma. Adjunctive thoracoscopic nodal sampling was 100% sensitive and 100% specific in diagnosing the mediastinal adenopathy. It did not significantly delay thoracotomy in cases of benign adenopathy. Visibility of the ipsilateral pleural space and mediastinum was excellent. Thoracoscopic exploration with mediastinal nodal sampling is a valuable diagnostic adjunct for assessment of adenopathy inaccessible to cervical mediastinoscopy and can overcome many of the limitations of anterior mediastinotomy.

Many thoracic surgical procedures previously performed using open thoracotomy techniques can now be accomplished using video-assisted thoracic surgical approaches. This has primarily resulted from improvements in both the video and surgical instrumentation and the development of an effective endoscopic surgical stapling device. Laser technology that has been adapted for use in endoscopic surgery has been extended to video-assisted thoracic surgical applications for the resection of pulmonary nodules difficult to manage with the endoscopic stapler alone. We present our experience with the neodymium:yttrium-aluminum garnet laser as either a primary resective tool or as an adjunct to the endoscopic stapler in 67 consecutive patients who underwent video-assisted thoracic surgical wedge resection of the lung.

For its first 80 years, thoracoscopy was primarily reserved for the evaluation and treatment of pleural disease. Extension of thoracoscopic techniques to management of parenchymal lung disease remained limited until the availability of endostaplers and adaption of video-assisted techniques through minimal access incisions. The widespread acceptance of mechanical staplers in open lung resections during the previous two decades has facilitated conversion to closed methods in the past 2 years. A variety of techniques for mechanical stapling in thoracoscopy are discussed. The impact of mechanical stapling in 300 consecutive thoracoscopic pulmonary resections is presented.

Background: Patients with diffuse pulmonary infiltrates often require biopsy for a diagnosis. Standard operative therapy, open wedge resection via thoracotomy, is associated with known morbidity. We hypothesized that closed thoracoscopic wedge resection may result in reduced morbidity and decreased duration of hospital stay. This retrospective study compares open resection with thoracoscopic wedge resection in patients with diffuse pulmonary infiltrates., Methods: Seventy-five patients with diffuse pulmonary infiltrates underwent diagnostic lung biopsy. Patients requiring mechanical ventilation and high levels of pressure support before biopsy were excluded from the study. Between March 1987 and September 1991, a total of 28 patients underwent open wedge resection via lateral thoracotomy. Since April 1991, a total of 47 patients underwent thoracoscopic resection., Results: There was no difference between the groups in age, sex, presence of immunosuppression, or final pathologic diagnosis. Adequate tissue was obtained for pathologic diagnosis in all patients of both groups. All surgeons believed that thoracoscopic biopsy provided better visualization of the entire lung than did a limited thoracotomy. Mean operative time was 69 minutes for open biopsies and 93 minutes for thoracoscopic biopsies [p = 0.038]. Mean duration of chest tube drainage was not significantly different between the two groups. Duration of hospital stay was significantly less for thoracoscopic biopsy (4.9 days) than for open biopsy (12.2 days) (p = 0.018). Fourteen of 28 open biopsies resulted in complications compared with 9 of 47 closed biopsies (p = 0.009). There were 6 deaths among patients having open biopsies and 3 deaths among those having closed biopsies (p = not significant)., Conclusion: A significant decrease in hospital stay was noted with thoracoscopic biopsy when compared with lung biopsy via the standard open approaches. Thoracoscopy provided excellent visualization and allowed for wedge resection that provided adequate tissue for diagnosis in patients with diffuse pulmonary interstitial disease.

The methods for vascular reconstruction of iliac arterial trauma can be a challenging problem. Primary arterial repair is usually possible, but an extensive injury may require interposition grafting or extra-anatomic bypass. Some investigators have advocated prosthetic grafting as a reasonable method of repair for complex iliac arterial injuries. We challenge this concept and describe our experience with the exclusive use of autogenous vascular repair during involvement with 87 consecutive patients surviving iliac arterial trauma.

Septal myectomy with a noncontact carbon dioxide laser for hypertrophic cardiomyopathy is described. This technique results in improved visualization of the septum as the laser beam is held outside the heart and the resecting laser beam can always be clearly seen. We believe this approach provides an improved method of septal myectomy in hypertrophic cardiomyopathy.

Objective: Laser-assisted thoracic surgery (performed through a thoracotomy or as an endoscopic procedure with thoracoscopy [pleural endoscopy]) is being used increasingly for lung-sparing resections of neoplasms, biopsies, and ablation of bullae. The technique is useful in treating patients who have limited pulmonary reserve and may avoid the problem of distortion of surrounding pulmonary tissue. Because laser energy causes injury to lung tissue, postoperative radiographs may show findings unique to the laser-assisted technique. The objective of this study was to determine postoperative radiographic findings common to laser-assisted surgery., Materials and Methods: Pre- and postoperative and all follow-up chest radiographs were reviewed for 52 consecutive patients who had 60 laser-assisted thoracic surgical procedures (35 with an open thoracotomy, 25 with thoracoscopy) for resection of peripheral nodules (40), biopsy of focal (five) or diffuse (four) lung disease, or ablation of bullae (three). Postoperative chest CT studies available for 20 patients also were reviewed. All postoperative radiographic studies were evaluated for the presence and duration of pneumothoraces, pleural effusions, areas of parenchymal opacification or cavitation, and complications requiring surgical or radiologic intervention., Results: Pneumothoraces and pleural effusions were seen in 88% and 83% of cases, respectively, and were typically small, uncomplicated, and of limited duration. Nonspecific parenchymal opacification of various degrees was observed at the operative site in all cases and usually regressed within days or weeks to areas of parenchymal scarring. Parenchymal cavitation at the operative site occurred in 15 patients (29%). Eight patients (15%) had complications that required intervention, primarily prolonged air leaks and pleural space complications., Conclusion: Radiographic findings after laser-assisted thoracic surgery are often nonspecific and of limited duration. In an asymptomatic patient, cavitation at the operative site is a normal finding related to the surgical technique and should not be misdiagnosed as infection or tumor. Radiographic findings normally resolve to stable cavitary or linear scars.

Surgical management of symptomatic benign and malignant effusive pericarditis is often required. Twenty-two patients with medically recalcitrant effusive, nonconstrictive pericarditis underwent pericardial resection by a video-assisted thoracoscopic surgical (VATS) technique (9 malignant, 13 benign). Pericardiectomy, resulting in complete drainage of the pericardial space and control of patient symptoms was accomplished routinely. Ipsilateral pleural effusions, originally present in 11 patients, were also managed. The VATS pericardiectomy was well tolerated even by gravely ill patients. This approach should be considered as an alternative to lateral thoracotomy or subxiphoid pericardial window for the surgical management of patients with symptomatic benign and malignant pericardial effusions.

Video-assisted thoracoscopy has recently evolved as an alternative to thoracotomy for several thoracic disorders. Spontaneous pneumothorax may be ideally suited for thoracoscopic management. Stapling of apical blebs and pleurodesis or pleurectomy can now be performed thoracoscopically in a fashion identical to the standard operation done through a lateral or axillary thoracotomy. We compared our results with thoracoscopic management of spontaneous pneumothorax in 26 patients (group I) with a group of 20 patients previously subjected to axillary thoracotomy (group II). Indications for operation, sex distribution, and average age (group I, 32.3 years; group II, 33.7 years) were comparable. Hospital stay was less in group I (2.88 +/- 0.99 days versus 4.47 +/- 1.07 days; p = 0.07), as was the use of parenteral narcotics after 48 hours (2/26 = 7.7% versus 14/20 = 70%; p = 0.01). There have been no recurrences to date (mean follow-up, 8 months) in the thoracoscopic group. Video-assisted thoracoscopic management of spontaneous pneumothorax allows performance of the standard surgical procedure while avoiding the thoracotomy incision. Video-assisted thoracoscopic management is safe and offers the potential benefits of shorter hospital stays and less pain.

Advances in endoscopic surgical techniques and laser technology have expanded the role of thoracoscopy. We report a thoracoscopic resection of a benign pulmonary lesion. A 44-year-old man underwent a successful Nd:YAG laser-assisted thoracoscopic resection of a peripheral lung hamartoma. The patient's postoperative course was uncomplicated. Thoracotomy with its attendant morbidity was avoided. Continued success with thoracoscopic resection will have a significant impact on the management of select patients with peripheral, solitary pulmonary nodules.

Objective: To describe the use of thoracoscopic techniques to achieve parenchymal sparing wedge resection of peripheral lung lesions in patients with a history of malignancy, and to describe the morbidity, mortality, and hospital course associated with this approach., Design: Case series., Setting: University hospital., Participants: Patients with a history of malignancy and lesions on computerized tomography in the outer one third of the lung parenchyma., Main Outcome Measurements: Histologic analysis of resected lung lesions, operative findings, operative time, duration of chest tube drainage and hospital stay, operative morbidity, and mortality., Results: Twenty-one thoracoscopic resections of pulmonary parenchymal lesions were performed on 15 patients. All peripheral lesions identified by computerized tomography were found at thoracoscopy and successfully resected with the Nd:YAG laser (n = 7), an endoscopic stapler (n = 10), or both (n = 4). The mean diameter of the lesions was 0.8 cm (range 0.2 to 1.5 cm). Histologic analysis revealed metastatic disease in 13 patients and benign disease in 2 patients. All resection margins were free of tumor. The mean duration of chest tube drainage and postoperative hospital stay were 1.8 +/- 0.1 and 3.3 +/- 0.1 days, respectively. Mean operative time was 111 min (range 45 to 155 min). One patient who underwent a right thoracoscopic resection developed a transient left vocal cord paresis. There were no other complications and no deaths., Conclusion: Thoracoscopy was successful in identifying peripheral lung lesions and allowed for parenchymal sparing resection identical in extent to that performed with open approaches. For select patients with peripheral lung nodules felt to be metastases, thoracoscopic resection may result in reduced morbidity, cost, hospital stay and allow for more rapid institution of therapy for the primary disease.

Despite recent advances in endoscopic surgical techniques, small nonpalpable peripheral pulmonary nodules may not be amenable to thoracoscopic resection. To facilitate resection in such cases, a technique of percutaneous needle localization involving use of a conventional mammographic needle localization system and computed tomographic guidance was developed. The technique has been used successfully in localization of 19 peripheral pulmonary nodules in 20 patients referred for thoracoscopic surgery.

Background: Patients with a history of malignant disease and new pulmonary lesions often are considered for resection to establish a diagnosis and, with certain histologic subtypes, to improve survival. Standard operative therapy consists of thoracotomy and wedge resection of the lesion. Early and late postoperative morbidity is substantial and related primarily to the thoracotomy incision., Methods: Advances in endoscopic surgical techniques and laser technology allowed for successful thoracoscopic resection of an isolated pulmonary metastasis in a 59-year-old man with a history of a T3N0M0 renal cell carcinoma., Results: The margins of the specimen were free of tumor. The postoperative course was uncomplicated, and the patient was discharged on the fourth postoperative day. The morbidity associated with a standard thoracotomy was avoided, and an adequate resection was obtained., Conclusion: Continued success with thoracoscopic resection may have a significant impact on the management of selected patients with a history of malignant disease and new pulmonary lesions.

Advances in endoscopic instrumentation and a growing enthusiasm for minimally invasive surgical techniques have sparked renewed interest in therapeutic thoracoscopy. We report the successful thoracoscopic resection of a posterior mediastinal nerve sheath tumor. A 35-year-old asymptomatic woman was found to have a posterior mediastinal mass on chest roentgenogram. Computed tomography and magnetic resonance imaging confirmed the presence of the lesion and showed no evidence of intraspinal extension. Exploratory thoracoscopy revealed a localized lesion without intraspinal extension. Thoracoscopic resection of the lesion was then performed. The patient's postoperative course was uncomplicated and she was discharged on the fifth postoperative day. The therapeutic potential of thoracoscopy continues to be realized as experience with the technique grows.

Video-assisted thoracic surgery is emerging as a viable approach to a number of intrathoracic disorders. Technical difficulties related to improper instrument selection and suboptimal intercostal operative access can reduce the utility of, and the enthusiasm for, the video-assisted thoracic surgical approach. This report describes the intercostal access strategy and the instrument positioning that we now prescribe for many video-assisted thoracic surgical procedures. These approaches have become refined during the course of our experience with 467 patients undergoing video-assisted thoracic operations over the last 18 months.

Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (less than 3 cm) in the outer third of the lung. Patients with preoperative histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttrium-aluminum garnet laser (31), endoscopic stapler (29), or both (25). The mean diameter of the lesions was 1.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2), bleeding requiring transfusion (1), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drainage was 3.3 +/- 3.0 days. Mean postoperative stay was 5.7 +/- 4.9 days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 15; radiation fibrosis, 1; sclerosing hemangioma, 1; rheumatoid nodules, 1; granuloma, 2; nocardia, 1; infarct, 1; hamartoma, 4; scar, 1; cytomegalovirus pneumonia, 1), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 13 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

The reported clinical use of the Sarns centrifugal pump (Sarns, Inc./3M, Ann Arbor, Mich.) as a cardiac assist device for postcardiotomy ventricular failure is limited. During a 25-month period ending November 1988, we used 40 Sarns centrifugal pumps as univentricular or biventricular cardiac assist devices in 27 patients who could not be weaned from cardiopulmonary bypass despite maximal pharmacologic and intraaortic balloon support. Eighteen men and nine women with a mean age of 60.4 years (28 to 83) required assistance. Left ventricular assist alone was used in 12 patients, right ventricular assist in 2, and biventricular assist in 13. The duration of assist ranged from 2 to 434 hours (median 45). Centrifugal assist was successful in weaning 100% of the patients. Ten of 27 patients (37%) improved hemodynamically, allowing removal of the device(s), and 5 of 27 (18.5%) survived hospitalization. Survival of patients requiring left ventricular assist only was 33.3% (4/12). Complications were common and included renal failure, hemorrhage, coagulopathy, ventricular arrhythmias, sepsis, cerebrovascular accident, and wound infection. During 3560 centrifugal pump hours, no pump thrombosis was observed. The Sarns centrifugal pump is an effective assist device when used to salvage patients who otherwise cannot be weaned from cardiopulmonary bypass. Statistical analysis of preoperative patient characteristics, operative risk factors, and postoperative complications failed to predict which patients would be weaned from cardiac assist or which would survive.

Four patients who recently developed massive spontaneous subcutaneous emphysema in our intensive care unit are reported. No obviously remediable intrathoracic process was found in any of these patients. The acute physiologic impairment and grotesque cosmetic deformity were immediately alleviated by making bilateral 3-cm infraclavicular incisions down to the pectoralis fascia. These acutely decompressed the progressive subcutaneous dissection and each patient's subcutaneous emphysema resolved without any additional invasive therapy.

The purpose of this study was to determine the most appropriate site of biopsy in patients with diffuse infiltrative lung disease (DILD). Twenty patients were evaluated. During open lung biopsy, a representative region (inflamed and least fibrotic) of the radiographically most involved lobe was identified and a biopsy done. A second biopsy specimen was obtained from an adjacent accessible lobe. The biopsy specimen from each lobe was processed separately, and a descriptive histologic report was generated for each of the two lobes. Tissue was cultured for bacteria, fungi, and mycobacteria. In 17 patients, the second biopsy site had fewer roentgenographic abnormalities than the radiographically most involved lobe. In 3 patients, the number of radiographic abnormalities was equal in all lobes. The same pathologic diagnosis was reached by histologic examination of the two biopsy specimens in 8 of 10 patients with acute DILD and in 10 of 10 patients with chronic DILD. In 2 patients, the biopsy specimen from the radiographically most involved lobe showed pathologic features not seen in the other specimen. Cultures from both biopsy specimens were grown separately in 6 patients. Fungi (n = 2) and bacteria (n = 1) were isolated from the radiographically most involved lobe (n = 2) or from the lobe of initial lung infiltration (n = 1) in 3 patients. When biopsy specimens are obtained from a representative region of the radiographically most involved lobe in patients with DILD, biopsy of other lobes is unnecessary.

The therapeutic role of thoracoscopy has expanded with advances in endoscopic surgical instrumentation and laser technology. We report a complete thoracoscopic resection of an encapsulated (stage I) thymoma with lymphocytic predominance in an elderly woman without myasthenia gravis. The patient had an uncomplicated postoperative course and was discharged on the third postoperative day. Median sternotomy with its attendant morbidity was avoided. Thoracoscopic resection of thymic neoplasms may be a useful approach in carefully selected patients.

There is little written in the literature regarding the management of major bronchial disruptions occurring during mediastinoscopy. This report illustrates the use of an in-continuity flap bronchoplasty of middle lobe bronchial tissue to repair such an iatrogenic intermediate bronchus injury.

The management of a patient with complete carotid bulbar disruption and transection of the ipsilateral cervical vertebral artery is presented. Internal carotid arterial emboli resulted in acute hemiparesis and altered consciousness. Total reconstruction of the carotid bulb was accomplished with reversed saphenous vein. Complete neurologic recovery was achieved. This approach of composite venous reconstruction of the carotid artery may be considered for selected patients with this complex vascular injury.

Paraesophageal herniation is a potentially devastating condition of the gastroesophageal hiatus commonly manifesting in patients of advanced age with other significant medical problems. Surgical treatment is generally indicated to avoid catastrophe related to gastric volvulus. The operative approach utilized should be individualized to the patient's pathophysiologic condition rather than attempting to apply a single repair for all patients with this heterogeneous clinical problem.

Eight patients with simultaneous penetrating trauma to the carotid and vertebral arteries among 129 carotid and 53 vertebral arterial injuries have been treated in the last 14 years. In contrast to a 10% mortality with isolated carotid or vertebral trauma, the mortality associated with this injury complex was 50%. This high mortality directly related to the overall complexity of the trauma sustained by these patients. The liberal use of arteriography to assess penetrating cervical trauma has enhanced the diagnosis of these injuries. We recommend simultaneous surgical management of the carotid and vertebral arterial injury through an extended anterior cervical approach.