THORACOSCOPIC SURGERY: INDICATIONS AND OUTCOME

Khaled Al-Kattan, FRCS

Background: Video-assisted thoracoscopic surgery (VATS) has become an established technique in both diagnostic and therapeutic thoracic surgery procedures.Patients and Methods: In an attempt to evaluate the current indications and outcome of this technique, 143 VATS procedures, which were performed over a three-year period, were retrospectively evaluated. Indications included lung biopsy in 46, recurrent or persistent pneumothorax in 42, and pleural disease in 16 patients. Other indications included sympathectomy in eight, mediastinal mass in three, pericardial window in three, metastasectomy in three, and staging of lung cancer in two patients.Results: There was one postoperative death (0.7%), a patient with massive pleural effusion and end-stage renal and hepatic failure. Conversion to formal thoracotomy was necessary in six patients (4.2%), and was the result of adhesions in four, bleeding in one, and failure to identify the lesion in one patient. Diagnostic procedures were considered successful in 44 out of 46 lung biopsies (95.7%), 15 out of 16 pleural disease cases (93.8%), and two lung cancer staging cases. The other 79 therapeutic VATS procedures were all effective, both in the long and short term, apart from two cases of prolonged air leak after VATS for pneumothorax, one of which was considered a failure (2.4%).Conclusion: VATS should be available in each thoracic surgery unit. It is both safe and effective in a variety of diagnostic and therapeutic procedures.Ann Saudi M ed 2000;20(2): 119-121.

Key Words: Thoracoscopy, pneumothorax, diagnosis.

In 1922, Jacobaeus from Stockholm reported his thoracoscopic experience over 12 years in managing pleural diseases.1 Improvements in endoscopic instruments and the introduction of the video-assisted technology have led to the widespread application of this technique.2 Video- assisted thoracoscopic surgery (VATS) has allowed surgeons to utilize the procedure not only for diagnosis, but also in a variety of therapeutic applications.

As the general principles of using this technique have become established, and with the availability of the operative setting, VATS is now being utilized to perform most diagnostic procedures, in addition to therapeutic operations, which include major surgical procedures such as pulmonary resection and esophagectomy in specialized centers. The advantages of VATS include less invasive access, shorter hospital stay and less postoperative pain.3 On the other hand, other considerations include cost, operative time, risks of one-lung ventilation and outcome. Diagnostic and simple therapeutic procedures done by VATS are now well established and strongly recommended by most thoracic surgery societies. Its use in major surgery and extended pulmonary resection is still debated,

From the Department of Surgery, King Khaled University Hospital, Riyadh, Saudi Arabia.

Address reprint requests and correspondence to Dr. Al-Kattan: P.O. Box 18097, Riyadh 11415, Saudi Arabia. E-mail: kkattan@kfshrc.edu.sa.

Accepted for publication 7 February 2000. Received 21 November 1999.

especially when dealing with malignancies, and when compared to muscle-sparing thoracotomies.4

In this paper, the indications for the use of VATS over a three-year period are described. They included both diagnostic and therapeutic procedures. The operative complications and outcome are discussed in an attempt to evaluate their value and limitations.

Patients and Methods

Between July 1995 and June 1998, all cases in which VATS was attempted or performed were reviewed. All procedures were performed at either King Khaled University Hospital (n=98) or King Faisal Specialist Hospital and Research Centre (n=45) in Riyadh. The indications and patient population varied according to the procedure required.

A total of 143 procedures were performed on 140 patients, comprising 61 females and 79 males, with an average age of 34 years (range, 5 to 72 years). There were 79 therapeutic and 64 diagnostic procedures. The latter included 16 VATSs for pleural disease in which additional therapeutic procedures were done at the same time for seven patients. Complete follow-up of the immediate results of the diagnostic procedures and the long-term effects (for the therapeutic ones) were available for all patients. All VATS was performed under general anesthesia, with double-lumen tube to achieve one-lung ventilation. The standard VATS utilized 3 ports and a 0-

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degree telescope. The number of ports and the use of the 30-degree scope varied in selected cases.

Results

VATS for Lung BiopsyThere were 46 patients (22 male and 24 female), with

an average age of 58 years (range, 34 to 72 years), who underwent VATS for lung biopsy. All patients were referred from the medical pulmonary service for open lung biopsy. Bronchoscopy was not diagnostic in 42 patients, and four patients were not fit for bronchoscopy. All had a recent computerized scan of the chest, which showed diffuse pattern of the disease in 38 and localized infiltrate in eight patients.

The decision of the side, site and number of thoracoscopic lung biopsies was dependent on radiological findings, clinical suspicions and the morphological appearance of the lung at operation. All specimens were sent fresh for histopathological and microbiological examination. Additional procedures, such as electron microscopy examination and immunohistochemical studies were performed when indicated.

Conversion to formal thoracotomy due to dense adhesions was necessary in three cases (6.5%). The average operative time was 45 minutes, and the mean duration of the intercostal tube drainage was 36 hours (range, 12 hours to 13 days). All specimens were reported to be adequate. Specific pathological diagnosis was made in 44 patients (95.6%).

VATS for PneumothoraxThere were 42 patients (40 male and two female), with

an average age of 28 (range, 18 to 56 years), who underwent VATS for pneumothorax. The underlying pathology was primary spontaneous pneumothorax in 36, and secondary pneumothorax (secondary to emphysema) in six patients. The indications for surgical intervention were recurrent pneumothorax in 32, and persistent air leak (more than seven days) in 10 patients.

All cases were performed thoracoscopically with three skin ports, with an average operative time of 52 minutes. The procedure included apical bullectomy and pleural abrasion for pleurodesis in all patients. Blebs were seen in 36 cases, but apical resection was done for all patients. Abrasion was performed with a mesh in 28, and by utilizing special rotatory brush in 14 patients. Chest drain under suction for 48 hours was the routine practice, followed by removal in the absence of air leak. The average duration of tube insertion was 3.5 days (range, 2 to 14 days). Prolonged air leak (more than 7 days) was noted in two patients. One patient required reinsertion of the tube after iatrogenic pneumothorax during tube removal. All patients had complete follow-up for an average period of 22 months (range, 2 to 36 months), with no evidence of recurrence.

VATS for Pleural DiseaseSixteen patients with pleural disease (10 male and 6

female) underwent VATS. Nine of these cases were performed for diagnostic purposes after failure of aspiration (n=6) or blind pleural biopsy (n=3). Additional pleurodesis was performed in late stages of the malignant disease. The indications for the therapeutic group were post-traumatic hemothorax in two, and management of fibrinous empyema in four patients. The latter included fibrinolysis, wash and drainage in three, while the last patient required conversion to thoracotomy due to adhesions.

VATS for SympathectomyFour patients who presented with hyperhydrosis of their

hands and axillae were offered thoracoscopic sympathectomy. The procedure was done bilaterally in three, and staged in one patient, a total of eight VATS procedures. All patients required one day of hospitalization. A mean follow-up of 14 months showed no evidence of recurrence.

VATS for Other Therapeutic ProceduresThe remaining 11 procedures were performed to

remove mediastinal tumors in three patients (two neurofibroma in the posterior mediastinum and one teratoma in the anterior mediastinum). In one patient with neurofibroma, a bleeding intercostal artery was noted at the end of the procedure, which necessitated a small thoracotomy incision for its control. Three patients with pericardial effusion had thoracoscopic pericardial window. Three patients with solitary pulmonary metastasis secondary to osteosarcoma were offered VATS. One patient required a formal thoracotomy due to the presence of multiple lesions, while the remaining two underwent successful VATS procedures. Two patients with adenocarcinoma of the left upper lobe had VATS staging and mediastinal lymph node biopsy from the para-aortic and subaortic stations.

The overall results showed one operative death (0.7%), a 4.2% conversion rate (six patients), and satisfactory outcome in all but four patients (97.2%). Failure was considered in nonspecific diagnosis of two of the lung biopsies, one of the pleural empyema required decortication, and one of the VATS bullectomies and pleurodesis for recurrent pneumothorax had early recurrence.

Discussion

The role of thoracoscopy has evolved over the last 10 years. Although its early use as a pleuroscopy proved to be successful in the diagnosis of pleural diseases, its role as a therapeutic tool only started after the presence of video- assisted facilities.5 VATS has gained support among many thoracic surgeons due to its multiple advantages over

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formal thoracotomies. It provides minimally invasive access to perform surgical procedures. There is less post-operative pain, as well as fewer postoperative complications, especially atelectasis and chest infection. It is cost effective, due to shorter hospital stay, and gives a better cosmetic appearance. On the other hand, the absolute indications for the use of VATS should be the performance of a noncompromised procedure which can influence the outcome.

The major role of VATS in diagnostic procedures is now well established. The need for diagnostic open-lung biopsies in a patient with undiagnosed generalized or localized lung disease is well achieved with VATS lung biopsy.6 The case should be well studied and investigated, and bronchoscopy and biopsy should usually be tried beforehand. A computerized scan of the chest should be available, and the decision of the site of the biopsy should correlate with the radiological findings. The need for more than one site is sometimes planned and occasionally an operative decision depends on the operative findings. The same would apply to pleural biopsy, but for both diagnostic and therapeutic reasons. With the results of a frozen section, pleurodesis can be performed for metastatic malignant diseases at the same setting.7

Staging of lung cancer by thoracoscopy is gaining progressive support in reducing the incidence of exploration thoracotomies for inoperable cases.8 Therapeutic applications require more skill to perform non-compromised procedures and to ensure an outcome similar to open techniques. In cases of recurrent pneumothorax or persistent air leak, apical bullectomy with pleurodesis is the treatment of choice and can be well achieved by VATS.9

The pleurodesis technique we prefer is pleural abrasion with either a mesh or special brush. Both techniques gave similar outcome with satisfactory long-term results in a previous study at our institute.10 Abrasion should not be limited to apical pleura, and should involve areas up to the diaphragm. Pleurectomy or talc pleurodesis are reserved for older patients with secondary recurrent pneumothorax in whom lung transplantation or volume reduction surgery are not a future possibility. We have recently published our experience of the management of empyema and tuberculous empyema.11 In the exudative or the fibrinolytic phase, early thoracoscopic intervention ensures adequate drainage, short hospital stay and good results.

Delayed intervention can lead to the development of organizing empyema, which requires decortication. The same would apply to organized hematoma due to delayed drainage either postoperative or post-trauma.

Sympathectomy for palmar and/or axillary hyperhydrosis is well established. With the introduction of VATS, the procedure can be done bilaterally, with a short hospital stay and excellent outcome.8

The utilization of VATS in other therapeutic procedures is still being debated. The general principle is that the procedure should not be compromised due to different access. Resection of mediastinal masses such as thymoma or neurofibroma is usually feasible with experienced hands. A liberal policy of conversion to thoracotomy should be the rule in case of difficulties, complications or inadequate removal. Pulmonary metastasectomy is widely practiced, and in our institute, we limit the use of VATS to solitary osteosarcoma and pulmonary metastasis.8 In these selected cases, the nodule can be identified and resected safely with free resected margins. Staging of lung or esophageal carcinoma may require thoracoscopy and lymph node biopsy in selected cases. Resistant pericardial effusion can be treated with thoracoscopic pericardial window with good results. Caution should be exercised in tuberculous pericarditis.

In general, the VATS procedure should have a good diagnostic and therapeutic outcome. Its use should be associated with low morbidity and mortality. The presence of a qualified, well-trained surgeon, experienced anesthetist, and an equipped theater is mandatory. VATS should be part of every thoracic surgery unit and its further use in more complex surgery such as lung resection for malignancy is yet to be established.

References

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3. Kaiser LR. Video-assisted thoracic surgery: current state of the art. Ann Surg 1994;220:720-34.

4. Shennib HA, Landreneau RJ, Nulder DS, Mack M. Video-assisted thoracoscopic wedge resection of T1 lung cancer in high-risk patients. Ann Surg 1993;218:555-60.

5. Landreneau RJ, Keenan RJ, Hazelrigg SR, Mack MJ, Naunheim KS. Thoracoscopy for empyema and hemothorax. Chest 1996;109:18-24.

6. Wakabayashi A. Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;102:721-3.

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10. Al-Kattan K. Pleural abrasion technique in management of pneumothorax. In: George Antypas, editor. International Congress of Thoracic Surgery. Greece: Monduzi Editore, 1997;1:347-50.

11. Al-Kattan K, Rafay M, Sawaf H, Ishaque N, Hajjar W, Ashour M. Surgery in tuberculous and past tuberculous empyema. International Congress of Thoracic Surgery. Editric Compositori (Italy), 1998;2:29-32.

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