Page 49 - World Association of Laparoscopic Surgeons - Journal

Atul Soni et al

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reported. Overall, malignant lesions comprise 44% of all instrumentation, thoracic surgeons are also performing
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SPN, and most (35%) are bronchogenic cancer. The risk VATS procedures for many indications previously reserved
of malignancy depends on nodule size, growth rate, patient for open thoracotomy.
age, patient smoking exposure and certain radiographic Lung nodules, pleural effusions, and pulmonary
findings. 41-43 infiltrates were the most common indications for VATS
Integrated approaches for the evaluation and procedures. Procedures performed most commonly were
management of SPN are described elsewhere. 42-45 Options wedge resection, pleural biopsy, pleurodesis and lung
for managing the SPN include observation, assessment by biopsy. Prolonged air leak was the most common
noninvasive imaging, cytologic or histologic investigation complication.
by transthoracic needle biopsy (TTNB) or bronchoscopy,
Current Role of Interventional Thoracoscopy for
and surgical resection. TTNB has a diagnostic sensitivity
each of Its Operative Applications
ranging from 43 to 97% for malignant lesions but is less
effective in yielding a definitive benign diagnosis. 45 But, Pleural Applications
TRNB is complicated by pneumothorax in approximately Empyema thoracis remains a condition with substantial
15% of patients. 43-45 It also has a false-positive rate of 1.5 morbidity and mortality. Selected empyemas can be
to 3%; the false-negative rate in the presence of malignancy satisfactorily decompressed with conservative regimens of
ranges from 3 to 11%. 46-48 Bronchoscopy is useful for larger repeated thoracentesis, or closed tube thoracostomy. More
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central lesions but has low diagnostic yield, approximately aggressive surgical approaches include open drainage
10%, for small peripheral lesions. 49,50 If malignancy or a procedures, decortication and thoracoplasty. Recently,
definitive benign diagnosis has not been proved by these thoracoscopy with repeated irrigation of the thoracic cavity
less invasive procedures, the SPN can be approached has been described. Thoracoscopic success depends on the
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surgically. Mack et al from three collaborative institutions, mechanical removal of infected material and ensuring fun
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excised by VATS under general anesthesia undiagnosed lung reexpansion. Wakabayashi described 20 patients who
selected SPNs in 242 patients. If the nodule was not pleural underwent debridement of chronic empyema by
based or immediately subpleural, preoperative needle thoracoscopy through a small incision; the lungs reexpanded
localization was used. Wedge excisions were performed in 18 (90%). The lung failed to reexpand in two patients,
using an endostapler alone (72%), a laser (18%), or both both whom had empyema of more than 4 months’ duration.
(10%). Only two patients required conversion to open Ridley and Braimbridge 51 reported overall complete
thoracotomy because of technical difficulties. resolution of empyema in 18 of 30 (60%) selected patients
A definitive diagnosis was made in every patient. A specific even though many were investigated at a late stage after
benign diagnosis was obtained in 127 (52%) patients and a initial treatment regimens had failed. Of the 12 patients who
malignant diagnosis in 115 (48%). Of the malignant nodules, did not have complete resolution after thoracoscopy, the
51 (44%) were primary lung carcinomas and 64 (56%) were empyema resolved in eight (66%) patients after open
metastases. If the nodule was determined to be a primary surgical procedures. Thoracoscopic debridement may
lung malignancy, and the patient had adequate pulmonary provide valuable time to improve the clinical condition of
function (n = 29), an immediate thoracotomy and lobectomy debilitated patients until they can tolerate more aggressive
were performed to ensure adequate resection. There was surgical approaches. However, critics have argued that
no mortality and the complication rate was 3.6% in the group thoracoscopic debridement delays definitive treatment as
who underwent thoracoscopy alone. The average hospital evidenced by Ridley’s 12 (40%) patients who subsequently
stay for the patients who underwent thoracoscopy alone was needed additional surgery after thoracoscopic evacuation
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2.6 days. Although this report demonstrated 100% failed. Patient selection and the stage of the empyema at
diagnostic sensitivity and specificity for an SPN, the exact intervention are the main determinates of outcome for
role and optimal timing of thoracoscopy in the management thoracoscopic debridement of empyema. During the
of SPN is currently not determined. exudative and organizing phase of empyema, thoracoscopic
visualization allows debridement of fibrinous adhesions and
THERAPEUTIC AND OPERATIVE 32
evacuation of loculated fluid. The timing of thoracoscopic
APPLICATIONS OF THORACOSCOPY
intervention is critical, however, and should be considered
Overview of simple rigid thoracoscopy is still used for when chest tube drainage is unsatisfactory after 3 to 5 days.
effusion management, pneumothorax repair and drainage If thoracoscopy is used, it is important to evacuate the
of uncomplicated empyema or hemothorax. With the empyema early before adhesions become too dense and an
development of endostaplers and refinements in organized ‘peel’ develops. 29 The use of thoracoscopy for

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